BJ216  H46 


RECAP 


:iiMM§r 


Columbia  ^Hnibers^itp 
in  tfje  €it^  of  ^ein  Sovk 

CoHege  of  ^{jpgician^  anb  burgeons; 


l^eference  %ihvaxv 


Principles  and  Practice  of 
Infant  Feeding 


BY 

JULIUS  H.  HESS,   M.D. 

Major  M.R.C.,   U.   S.   Army,   Active  Service. 

Professor  and  Head   of   the  Department  of  Pediatrics,   University  of 

Illinois  College  of  Medicine;  Chief  of  Pediatric  Staff,  Cook  County 

Hospital;    Attending    Pediatrician    to    Cook    County,     Michael 

Reese    and    Englewood    Hospitals,     Chicago. 


ILLUSTRATED 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  Publishers 

English  Depot 

Stanley  Phillips,  London 

1918 


CONTENTS. 


Part  I. 

PAGE 

General   Considerations    1 

Chapter  I.  The  Anatomy  of  the  Digestive  Tract  of  the  Infant  1 
Chapter  II,  The   Physiology  of  the  Digestive  Tract  of   the 

Infant    4 

Chapter  III.  Metabolism;  in  Infants   7 

1.  General  Considerations   7 

2.  Composition    of    Milk    and    the    Metabolism    of    its 

Constituents    8 

3.  Milk  Digestion    20 

Chapter  IV.  Bacteria  of  the  Digestive  Tract  of  the  Infant.  25 

1.  The  Newborn 25 

2.  The  Nursing  Infant  25 

3.  Artificially  Fed   Infants    27 

4.  Significance  of  the  Intestinal  Bacteria   28 

5.  Influence  of  the  Diet  on  the  Intestinal  Flora  29 

6.  Intestinal   Bacteria   in   their    Relation   to   Gastro-in- 

testinal    Disturbances    31 

Part  II. 

The  Nursing    35 

Chapter  I.  General  Considerations    35 

Chapter  II.  Maternal  Nursing  39 

1.  Nursing  Axioms    39 

2.  Hygiene  of  the  Mother  39 

3.  Conditions  Influencing  the  Breast  Milk   42 

4.  The  Nursing  Proper   43 

Chapter  III.  Wet-nursing   47 

1.  The  Wet-nurse;  Her  Selection  and  Her  Baby  47 

2.  The  Hygiene  of  the  Wet-nurse   54 

3.  The    Nursing    58 

Chapter  IV.  The  Nursing  Infant    64 

Chapter  V.  Mixed  Feeding  and  Weaning  67 

Chapter    VI.  Nutritional     Disturbances     in     the     Breast-fed 

Infant    71 

1.  Underfeeding    71 

2.  Overfeeding    76 

3.  Congenital   Debility,   with   Resulting  impairment  of 

Vital  Functions 84 

4.  Intercurrent  Parenteral  and  Enteral  Infections   ....  85 

5.  Idiosyncrasy  towards  Mother's  Milk   87 

(vii) 


viii  CONTENTS. 

PAGE 

Chapter  VII.  Methods  of  Feeding  Premature  Infants 89 

1.  Infants  Nursing  at  the  Breast   89 

2.  Infants  too  ^^'eak  to  Nurse  the  Breasts    90 

3.  Proper  Time  for  Beginning  Regular  Feeding   96 

4.  Feeding  from  the  Second  to  the  Tenth  Day 97 

5.  Feeding  After  the  First  Ten  Days    99 

6.  Number  of  Feedings  Daih'  100 

7.  The  Amount  of  Each  Feeding  101 

S.  Daily  Gains   102 

9.  Artihcial  Feeding    102 

10.  Conclusions 105 


Part  III. 

Artificial  Feeding    107 

Chapter  I.  Recent  Progress  in  Artificial  Feeding 107 

Chapter  II.  Cow's  Milk  110 

Chapter  III.  Adaptation  of  Milk  for  Infant  Feeding 124 

1.  Undiluted  Whole  Milk 126 

2.  The  Percentage  Method  or  System  of  Feeding  ....  126 

3.  Top   Milk  Feeding   , .'. 127 

Chapter    IV.  Milk    Dilutions   with    the    Addition    of    Carbo- 
hydrates        129 

Chapter  V.  Feeding  in  Late  Infancy  and  Early  Childhood  .  .    164 

Part  R'. 

Nutritional  Disturbances  in  Artificially  Fed  Infants   168 

Chapter  I.  Minor  Disturbances   168 

1.  Stationary  Weight    168 

2.  Vomiting    168 

3.  Colic  and  Flatulence    169 

4.  Constipation    170 

5.  Abnormal  Stools   171 

6.  Milk    Idiosyncrasy    ■  173 

Chapter    II.  General    Consideration    of    Nutritional    Disturb- 
ances       175 

Chapter  III.  Disturbed  Metabolic  Balance   186 

Chapter  IV.  The  Stage  of  Dyspepsia  196 

Chapter  V.  The  Stage  of  Decomposition    207 

Chapter  VI.  The  Stage  of  Alimentary  Intoxication   223 

Chapter  VII.  Mixed  Forms  of  Nutritional  Disturbances  ....  237 
Chapter  VIII.  Nutritional   Disturbances   Due  to   Insufficient 

Food    238 


CONTENTS.  ix 

PAGE 

Chapter  IX.  Infection  and  Nutrition    245 

1.  Susceptibility   Influenced   by  Nutrition    245 

2.  Course  of  Infections  Influenced  by  Nutrition   246 

3.  Infection  Influencing  Nutrition    247 

(A)  Parenteral  Infections    248 

(B)  Enteral    Infections    254 

Appendix. 

Proprietary  Baby  P'oods    273 

Directions  for  the  Preparation  of  Infant's  Foods  279 

Bottles  and  Nipples  and  their  Care  295 

Care  of  Food  During  Traveling 297 

The  Diaper 298 

Baby's  Daily  Bath  300 

Cold  Bath  and  Cold  Pack  302 

Hot  Bath    303 

Mustard  Bath  and  Mustard  Pack  303 

Stomach  Washing    304 

Catheter  Feeding  by  Mouth    305 

Catheter  Feeding  by  Nose   306 

Irrigation  of  the  Colon  and  Rectal  Feeding ' 306 

Saline  Solutions    308 

Home-made  Ice-box 310 

Case  History 312 

Average    Weights    314 

Measurements    314 

General  Development    315 

Sleep    315 

Order  and  Average  Time  of  Eruption  of  the  20  Deciduous 

Teeth    315 

Permanent  Teeth   316 

Closure  of  Fontanels   316 

Average  Daily  Quantity  of  Urine  in  Health 316 

Average  Rate  of  Pulse  and  Respiratio^   316 

Blood-picture  in  Healthy  Children  317 

Average  White   Cell   Counts 317 

Stool    Symbols 317 

Urine  Symbols  317 

Record  Sheet  318 

Index    325 


INTRODUCTION. 


The  dependence  of  the  offspring  upon  its  mother  for 
food  to  supply  its  primitive  needs  can  only  be  realized 
when  we  remember  that  one-fourth  of  the  civilized  race 
die  during  the  first  year  of  life,  and'  that  60  per  cent,  of 
these  deaths  are  due  to  nutritional  disturbances,  while  a 
large  portion  of  the  other  40  per  cent,  are  primarily  de- 
pendent upon  impairment  of  the  infant's  constitution  by 
improper  feeding.  The  mortality  of  the  first  year  is 
nearly  60  times  that  of  the  fifteenth  year,  and  it  is  not 
until  we  approach  the  85th  year  that  we  meet  with  such 
a  high  percentage  death-rate.  The  problem  is  not  simply 
to  save  life  during  the  perilous  first  year,  but  to  adopt 
those  means  which  shall  tend  to  healthy  growth  and  nor- 
mal development.  The  child  must  be  fed  not  only  to 
avoid  the  immediate  dangers  of  acute  indigestion,  diar- 
rhea, and  marasmus,  but  the  more  remote  ones — rickets, 
scurvy,  and  general  malnutrition.  These  latter  three  are 
the  most  important  conditions  that  predispose  to  disease 
in  early  life. 

A  growing  child  requires  far  more  food  than  its 
weight  would  indicate.  For,  in  the  first  place,  its  intake 
must  exceed  its  expenditure,  so  that  it  may  grow.  The 
expenditure  of  an  organism  is  pretty  nearly  in  propor- 
tion, not  to  its  mass,  but  to  its  surface.  The  skin  surface 
of  a  boy  from  6  to  9  years,  with  a  body  weight  of  18  to 
24  kilograms  (40  to  50  pounds),  is  two-fifths  to  one-half 
that  of  a  man  of  70  kilograms  (154  pounds),  and  he 
should  therefore  have  about  half  as  much  food  as  the 

(xi) 


xii  INTRODUCTION. 

man.  This  disproportion  in  the  needs  of  the  infant  as 
compared  with  the  adult,  is  even  greater  than  that  of  the 
child  compared  with  the  adult.  By  exact  measurements 
it  has  been  determined  that  an  infant  from  its  fourth  to 
the  sixth  month  consumes  about  twice  as  much  food  per 
kilogram  body  weight  as  the  adult. 


Part  I. 

General  Considerations. 


CHAPTER    I. 

THE   ANATOMY    OF   THE    DIGESTIVE    TRACT 
OF    THE    INFANT. 

Oral  Cavity.  The  salivary  glands  are  well  developed 
at  birth,  and  the  active  principles  of  the  salivary  secre- 
tion are  present,  but  in  small  quantities.  Teething  begins 
at  about  the  sixth  month,  and  dentition  is  not  completed 
until  about  the  end  of  the  second  year.  In  most  instances 
this  is  a  normal  physiological  process,  and  should  cause 
no  disturbances.  However,  in  a  considerable  number  of 
cases  the  gastric  and  intestinal  secretions  are  affected  re- 
flexly,  with  a  diminished  activity  on  the  part  of  these 
glands ;  and  if  there  is  any  tendency  to  a  general  disturb- 
ance during  this  period,  a  reduction  in  the  quantity  of  the 
food  administered  is  indicated.  However,  far  too  great 
an  importance  is  usually  given  by  the  laity  to  the  process 
of  teething. 

Stomach.  In  the  newborn  the  stomach  has  a  more 
vertical  position  than  in  the  adult.  However,  rontgen- 
ologic examination  has  demonstrated  that  it  is  less  ver- 
tical than  has  been  formerly  supposed.  The  cardiac  end 
is  found  at  the  left  of  the  tenth  dorsal  vertebra.  The 
pylorus  lies  about  midway  between  the  ensiiorm  cartilage 
and  the  umbilicus.  The  position  of  the  stomach  and  its 
form,  due  to  lack  of  development  of  the  fundus  and  lack 

1  (1) 


2  INFANT   FEEDING. 

of  muscular  development  at  tlie  cardiac  end,  account  in 
great  part  for  the  frequency  of  vomiting  in  the  infant. 

The  pylorus  also  lacks  the  muscular  development  of 
the  adult,  and  is  decidedly  more  patent. 

Considerable  difficulty  is  experienced  in  our  attempts 
to  gain  accurate  knowledge  of  the  capacity  of  the  stom- 
ach. Pfaundler,  who  measured  the  size  of  numerous 
infants'  stomachs,  using  air  under  a  given  pressure,  has 
given  us  figures  which  are,  in  all  probability,  fairly 
accurate. 

He  states  that  the  capacity  at  birth  is  2  ounces  (60 
mils),  at  one  month  2  to  3  ounces  (60  to  90  mils),  at  six 
months  6  ounces  (180  mils),  and  at  one  year  9  to  10 
ounces  (270  to  300  mils).  The  importance  of  the  stom- 
ach's capacity  in  determining  the  size  of  the  individual 
feeding  is  only  relative,  dependent  to  a  great  extent  upon 
the  form  of  diet.  With  milk  as  the  food,  a  considerable 
portion  of  the  water  content  passes  through  the  pylorus 
before  the  meal  is  finished,  if  the  food  is  not  too  rapidly 
given.  When  a  child  is  fed  by  gavage,  the  size  of  the 
meal  is  of  greater  importance  because  of  the  danger  of 
overdistention  by  the  rapid  administration  of  the  food  by 
this  method.  Notwithstanding  the  fact  that  the  size  of 
the  stomach  varies  in  different  babies,  we  have  found  it  a 
good  working  rule  in  the  feeding  of  normal  infants  to 
administer  at  each  feeding  a  quantity  2  ounces  more  of 
the  liquid  food  than  the  infant  is  months  old. 

The  intestines  are  relatively  larger  than  in  the  adult, 
which  applies  more  especially  to  the  large  intestine,  and 
particularly  to  the  sigmoid  flexure.  -  The  sigmoid  is  also 
more  mobile,  due  to  the  greater  length  of  the  mesosig- 
moid,  and  it  is  extra-pelvic.  The  musculature  is  rela- 
tively thin,   and  bears  an  important  relationship  to  the 


ANATOMY   OF   THE    DIGESTIVE   TRACT.  3 

frequency  of  its  overdistention  and  the  presence  of  colic, 
which  is  due  to  the  stagnation  of  large  quantities  of  gas 
in  the  intestinal  tract. 

The  pancreas  shows  no  special  anatomical  differences. 

The  liver  is  relatively  two-and-a-half  times  as  large 
at  birth  as  in  the  adult,  and  is  easily  palpable,  and  in  the 
nipple-line  of  the  right  side  usually  extends  1  to  1^ 
inches  (2  to  4  cm.)  below  the  costal  border. 


CHAPTER    II. 

THE    PHYSIOLOGY    OF   THE   DIGESTIVE 
TRACT    OF    THE    INFANT. 

While  all  the  ferments  are  present  in  earty  life,  they 
vary  quantitatively  and  qualitatively  as  compared  with 
the  older  children. 

Mouth.  Ptyalin,  which  is  an  amylolytic  ferment,  is 
present  in  the  saliva  immediately  after  birth,  but  is  small 
in  amount,  and  weak  in  its  action.  Albumin,  water  and 
mucus  in  saliva  vary  with  the  variety  of  food  taken 
(Pavlow). 

Stomach.  Gastric  juice  is  present  in  the  stomach 
even  in  the  premature.  Its  secretion  is  mainly  stimu- 
lated by  the  act  of  sucking  and  by  the  presence  of  the 
food  in  the  stomach. 

Free  hydrochloric  acid  is  little  less  than  in  the  adult. 
It  may  be  stated  that  the  small  protein  content  of  human 
milk,  as  compared  with  cow's  milk,  favors  the  presence 
of  hydrochloric  acid.  This  is' a  point  of  great  importance 
in  the  food  problem  of  the  infant.  Free  hydrochloric 
acid  is  found  in  10  per  cent,  of  cases  after  1  hour,  and  in 
33  per  cent,  of  cases  after  XYi  hours  on  feeding  with 
human  milk  (Hamburger  and  Sperck).  With  cow's 
milk,  free  hydrochloric  acid  is  found  very  rarely,  which 
is  due  to  combination  of  the  hydrochloric  acid  with  salts 
and  proteins.  Total  acidity  is  in  small  part  only  due  to 
free  hydrochloric  acid.  ^lore  important  are  phosphoric 
acid,  acid  phosphates,  acid  chlorides,  fatty  acids  and  acid 
albumins  (  albumoses  and  peptones).  Total  acidity  is  20 
to  60  mils  X  :10  acid  to  100  mils  of  gastric  contents.    The 

(4) 


PHYSIOLOGY    OF    THE    DJGESTIVE    TRACT.  5 

action  of  the  hydrochloric  acid  is  as  follows:  (1)  makes 
protein  digestion  possible  (acid  albumins)  ;  (2)  stimu- 
lates the  pancreas;  (3)  disinfectant  and  antitoxic  action. 

The  following  ferments  are  present  in  the  stomach : 
(1)  Pepsin,  which  is  present  at  birth,  and  is  active  and 
causes  at  least  partial  chgestion  of  proteins.  It  increases 
to  the  fourth  month,  then  remains  fairly  constant.  More 
pepsin  is  present  in  bottle-fed  infants.  (2)  Rcnnin  is 
also  present  at  birth,  and  in  the  presence  of  hydrochloric 
acid  coagulates  milk.  Whether  this  is  dependent  on  pep- 
sin, or  whether  it  is  a  specific  ferment,  is  questionable. 
(3)  Lipase,  a  fat-splitting  ferment,  is  found  in  the  stom- 
ach in  small  quantities,  and  is  probably  a  definite  product 
of  the  gastric  mucosa. 

Small  Intestines.  Mucous  membrane  of  the  small 
intestines  secretes  about  1  liter  of  juice  daily,  and  this 
contains  all  ferments  at  birth,  they  being,  however,  rela- 
tively feeble  at  first.  The  following  ferments  are  pres- 
ent in  the  intestinal  secretion:  (1)  erepsin  (Cohnheim), 
which  splits  casein,  albumoses,  and  peptones  to  peptids 
and  amino-acids.  Other  albuminous  bodies  are  not 
afifected  by  it.  (2)  lactase,  maltase,  invertin;  they  split 
disaccharides  (milk,  malt,  and  cane  sugar)  to  monosac- 
charides, and  each  is  stimulated  by  its  own  sugar.  (3) 
prosecretin,  which  is  changed  to  secretin  by  hydrochloric 
acid  from  the  stomach,  and  stimulates  the  secretion  of 
the  pancreas.  (4)  enterokinase,  which  activates  the  pro- 
teolytic enzyme  of  the  pancreatic  juice;  and  probably  (5) 
diastase. 

Pancreas.  All  of  the  ferments  (trypsin,  steapsin, 
and  amylopsin)  are  found  in  the  intestines  at  birth. 

The  liver  possesses  the  ability  to  form  gtycogen  and 
iirea  in  the  newborn.     Bile  is  present,  its  emptying  from 


6  INFANT   FEEDING. 

the  gall-bladder  being  stimulated  by  chemical  action  of 
fats  on  the  duodenal  mucous  membrane.  The  functions 
of  the  bile  are:  (Ij  to  hold  fatty  acids  and  fatty  acid 
salts  in  solution,  (2)  to  stimulate  the  pancreas,  and  (3) 
an  antiseptic  action.  Other  functions  of  the  liver  are 
formation  of  urea,  acetone,  and  formation  and  storing 
of  glycogen. 

Large  intestines  secrete  no  enzymes,  their  chief 
function  being  absorption  of  water  and  throwing  off  of 
Ca,  P,  Xa,  K,  Fe,  Mg. 


CHAPTER    III. 
METABOLISM    IN    INFANTS. 

1.  General  Considerations. 

The  term  metabolism  covers  all  of  the  functions  of 
the  human  body  which  have  to  do  with  the  preparation 
for  and  assimilation  of  food. 

To  furnish  the  body  with  fuel  for  its  normal  activities, 
the  following  groups  of  food  elements  are  necessary : 
proteins,  fats,  carbohydrates,  salts,  and  water.  Fats  and 
carbohydrates,  and  to  a  lesser  extent  proteins,  furnish 
fuel ;  while  the  proteins  and  salts  more  especially  form 
the  elements  necessary  for  body  growth. 

It  is  necessary  to  distinguish  between  the  activities 
which  take  place  within  the  gastro-intestinal  tract  before 
absorption  of  the  changed  products  and  the  deeper  seated 
metabolism  which  takes  place  beyond  the  intestinal  wall, 
which  can  be  designated  as  the  "intermediary  me- 
tabolism." 

Under  normal  conditions  in  the  adults  the  intake  and 
the  products  of  excretion  balance  one  another,  while  in 
the  infant  there  is  a  positive  balance — that  is,  less  is  ex- 
creted than  is  absorbed — and  one  may  well  say  that  a 
balance  which  would  be  normal  in  the  adult  is  patho- 
logical in  the  child,  and  would  thereupon  soon  result  in 
a  stationary  weight,  or  a  loss  in  weight. 

Several  factors  offer  difficulties  in  the  study  of  infant 
metabolism. 

First,  it  is  difficult  to  obtain  stools  free  from  urine  and 
with  the  water  content  intact. 

(7) 


8  INFANT   FEEDING. 

Secondly,  the  small  volume  in  which  the  urine  and 
stools  are  obtained  offers  many  difficulties  in  their  study. 

Urine  and  stool  examinations  should  cover  a  period  of 
at  least  three  days  to  be  of  conclusive  value. 

2.  Composition  of  Milk  and  the  Metabolism 
of  Its  Constituents. 

The  natural  food  of  the  infant  is  human  milk,  char- 
acterized by  the  fact  that  its  quality  changes  very  little, 
the  infant's  growth  being  dependent  on  the  changes  of 
its  volume. 

Milk  of  different  animals  varies  as  to  its  fuel  value, 
and  also  in  its  chemical  composition,  especially  quan- 
titatively there  being  marked  differences. 

Protein  Fat  Sugar  Salts 

Human   1.5  3.5  6  to  7  0.20  per  cent. 

Cow's  3:4  3.8  4  to  5  0.75     "       " 

Human  colostrum  differs  from  the  milk  in  that  the 
protein  is  5  to  6  times  as  great  in  the  former ;  salts  are 
also  higher  than  in  later  milk ;  sugar  is  low — 3  to  5  per 
cent. — and  it  is  low  in  fats,  averaging  about  2  to  2.5  per 
cent.,  although  it  varies  in  different  women,  and  also 
with  the  day  of  puerperium.  Colostrum  contains  also 
numerous  leucocytes  and  large  cells  containing  fat,  these 
latter  probably  being  epithelial  in  origin. 

1.  Proteins.  Chemistry  of  Proteins.  Proteins  con- 
tain carbon,  hydrogen,  nitrogen,  oxygen,  sulphur,  and 
phosphorus.  They  are  highly  complex  chemical  sub- 
stances, similar  in  their  chemical  composition  to  proto- 
plasm and  essential  to  life. 

Of  the  proteins  milk  contains  mainly  casein  and  al- 
bumins, with  small  amounts  of  globulins,  opalisin, 
nuclein,  etc. 


Albumin 

0.6 

Casein 
0.8         per  cent. 

1.2  to  0.3 

2.7  to  3.0    "       " 

METABOLISM    IN    INFANTS. 

Human  milk  contains    .  .  . 

Cow's  milk  contains    0.2  to  0.3 

Casein  belongs  to  the  nucleo-albumin  group  (proteins), 
which  contain  phosphorus,  are  insoluble  in  water,  mod- 
erately in  alkalies,  precipitated  by  acids,  not  coagulated 
by  boiling,  and  by  pepsin  digestion  changed  to  para-  or 
pseudo-  nucleins  (which  are  bodies  rich  in  phosphorus). 
Chemically  it  is  composed  of  a  complex  group  of  amino- 
acids,  the  basis  of  all  protein  bodies,  and  a  prosthetic 
group  which  contains  the  phosphorus.  Amino-acids  are 
characterized  by  the  group  COOH,  in  which  an  H  is  re- 
placed by  NH2  group,  e.g.,  acetic  acid  (CH2HCOOH), 
amino-acetic  acid,  or  glykokoll  (CH2NH2COOH). 

Human  casein  contains  much  less  phosphorus  than 
cow's  (0.25  to  0.88).  This  proves  that  the  casein  of  the 
human  and  the  casein  of  the  cow's  milk  are  different 
bodies,  although  this  difference  is  probably  of  a  quanti- 
tative nature  only.  The  two  caseins  differ  also  in  their 
coagulability,  the  human  casein  being  more  difficult  to 
precipitate  with  acids,  salts  and  rennin.  The  soluble 
albumins  are  coagulated  by  heat  and  weak  acids. 

Metabolism  of  Proteins.  Casein  is  separated  from  the 
so-called  whey  albumin,  and  is  changed  to  an  insoluble 
paranuclein.  It  is  unknown  whether  enzyme  causing  it 
is  identical  with  the  protein  digestive  ferment  of  the  gas- 
tric mucous  membrane  or  not. 

Pepsin  (from  the  pyloric  mucous  membrane)  changes 
paranucleins  to  albumoses  and  peptones,  which  then  pass 
into  the  small  intestines.  (Erepsin,  the  ferment  of  the 
intestinal  juices,  works  very  rapidly  on  the  end  products 
of  pepsin  digestion.)  In  the  small  intestine  an  intricate 
splitting  takes  place. 


10  INFANT   FEEDING. 

With  the  human  milk  as  a  food,  a  very  small  amount 
of  nitrogenous  products  of  the  food  appears  in  the  stools, 
the  total  being  about  one-sixth  of  the  intake,  and  part  of 
this  arises  from 

1.  Intestinal  juices, 

2.  Intestinal  epithelium. 

3.  Bacterial  activity. 

After  passing  through  the  intestinal  wall,  proteins  have 
three  functions  to  perform : 

1.  To  replace  used  proteins  (lost  through  urine,  sweat, 
digestive  juices,  cell  destruction,  etc.). 

2.  To  satisfy  cell  growth  which  would  be  impossible 
without  proteins. 

3.  To  furnish  fuel  for  part  of  the  dynamic  loss  (fats 
and  carbohydrates  are  the  natural  fuels,  the  protein  com- 
bustion being  incidental). 

In  feeding  with  cow's  milk,  three  times  as  much  pro- 
tein is  given  as  needed  for  1  and  2,  therefore  it  is  used 
for  3  (that  is,  dynamic  purpose). 

The  great  disproportion  as  seen  in  a  comparison  of  the 
proteins  in  cow's  over  human  milk  is  probably  due  to  the 
needs  for  cell  growth  in  the  calf.  '  Within  certain  limits, 
however,  the  excess  of  protein  feeding  in  the  infant  does 
not  cause  increased  retention  and  cell  growth  because  of 
the  ability  of  the  organism  to  regulate  its  functions. 
End  Products  of  Protein  Metabolism  in  Urine: 
Urea  60  to  80  per  cent. 
Ammonia  3  to  10  per  cent. 
Oxaluric  bodies  1 

Uric  acid  !  ,^.  ,  , 

.   .  J- JNitrogenous  by-products. 

Kreatmm  j  ^  .r  f 

Oxybutyric  acid  j 


METABOLISM    IN    INFANTS.  11 

Urea  forms  75  to  86  per  cent,  of  the  nitrogen  con- 
stituents of  the  urine. 
By  ammonia  coefficient  is  meant  the  relation  of  am- 
monia to  the  other  nitrogenous  bodies  in  the  urine. 
Influence  of  the  Carbohydrates  and  Fats  on  the  Nitro- 
gen Metabolism. 

1.  Carbohydrates  cause 

(1)  Increased  retention  of  proteins. 

(2)  Increased  nitrogen  in  feces. 

2.  Fats  cause  J 

(1)  No  increased  protein  retention. 

(2)  Increased  nitrogen  in  feces. 

2.  Fats.  Chemistry  of  Fats.  Human  milk  fats  are 
esters  of  palmitic,  stearic,  and  oleic  acids  with  glycerin, 
the  oleic  acid  ester  being  present  in  larger  amount  in 
human  than  in  the  cow's  milk.  Human  milk  fats  are  de- 
rived partly  from  body  fat  and  partly  from  food  fat. 
Carbohydrates  also  furnish  ingredients  for  fat  making; 
proteins  do  not. 

Metabolism  of  Fats. 

1.  Lipase  from  the  gastric  mucous  membrane  causes 
some  splitting  of  fat. 

2.  Fats  are  emulsified  in  small  intestines. 

3.  Live  intestinal  cells  can  change  fatty  acids  to  fats. 
Resorption. 

1.  Lymph-vessels. 

2.  Blood-vessels. 
Disposition. 

1.  Subcutaneous  tissue. 

2.  Prseperitoneal  spaces. 

3.  Liver. 


12  INFANT   FEEDING. 

4.  Burned  with  resulting  end  products. 

(1)  Carbonic  acid. 

(2)  Water. 

In  stools  found  normally  as  unresorbed  portion  of  in- 
gested fat  in  the  form  of 

1.  Fat  (neutral). 

2.  Lecithin. 

3.  Cholesterin. 

4.  Fatty  acids  representing  1  to  10  per  cent,  of  fat 

ingested. 

5.  Alkali  soaps. 

6.  Earthy  alkali  soaps. 

In  Urine.  Fatty  acids  and  glycerin  are  found  in  very 
small  quantities,  but  we  cannot  say  that  these  are  from 
the  fats  ingested. 

Nursing  babies  always  have  at  least  a  small  amount  of 
fat  in  their  stools.  In  contradistinction  to  proteins,  the 
fats  in  the  stools  are  in  greater  part  only  unresorbed  fats, 
only  a  small  amount  being  due  to  cell  activity.  (Proteins 
greater  part). 

A^arious  percentages  of  fat  ingredients  normally  pres- 
ent in  human  stools  are,  as  follows : 

Neutral   fat    29.5  per  cent. 

Fatty  acids   10.7     " 

Combined  fatty  acids   ....   59.8     ''        "      (18.3  Ca  and  Mg.) 

Fat  in  the  Gastro-intestinal  Tract  and  its  Relation  to 
Metabolism.  Unlike  proteins  we  can  nourish  the  in- 
dividual without  fats,  as  carbohydrates  can  replace  them. 
If  too  long  continued,  the  organism  changes,  however,  m 
its  chemistry  through  increased  absorption  of  salts  and 
water,  which,  however,  lessens  the  processes  of  immunity. 


METABOLISM    IN    INFANTS.  13 

3.  Carbohydrates.  Milk  sugar  formed  by  the  mam- 
mary glands  from  material  circulating  in  the  blood  is  a 
disaccharide   (glucose  and  galactose). 

Chemistry  of  Carbohydrates. 

1.  Monosaccharides. 

(1)  Glucose  (dextrose,  grape  sugatr). 

(2)  Lsevulose  (fruit  sugar). 

They  ferment  and  are  reducible.     (1)  Has 
a  right  and  (2)  left  polarization. 

2.  Disaccharides. 

(1)  Lactose — glucose  and  galactose. 

(2)  Maltose — glucose  and  glucose. 

(3)  Saccharose — glucose  and  Isevulose. 
(1)  and  (2)  are  reducible,  (3)  is  not. 

3.  Polysaccharides  (three  or  more  sugar  molecules). 

(1)  Flour. 

(2)  Dextrin. 

(3)  Cellulose. 

Metabolism  of  Carbohydrates.  Monosaccharides  are 
without  further  change  absorbed  in  the  small  intestine 
or  fermented. 

Disaccharides  are  first  reduced  to  monosaccharides  by 
the  intestinal  ferments  (every  disaccharide  having  its 
specific  ferment)  before  they  can  be  absorbed.  (This  is 
not  entirely  true  of  maltose). 

Polysaccharides  are  first  acted  upon  by  ptyaline  in  the 
saliva ;  this  is  continued  in  the  stomach  until  the  stomach 
content  becomes  acid,  and  then  by  enzymes  of  intestines 
and  pancreas  they  are  converted  to  monosaccharides. 

After  absorption  into  the  blood,  the  carbohydrates 
serve  the  following  purposes  : 


14  INFANT   FEEDING. 

1.  Used  for  energy. 

2.  Synthetically  inverted  into  glycogen. 

3.  Fat  foundation  (probably). 

Body  cells  can  oxidize  only  monosaccharides  (maltose 
excepted). 

Interesting  is  the  storing  up  of  glycogen  by  the  liver 
and  muscles  so  that  the  sugar  in  the  blood  can  be  kept 
constantly  at  about  0.1  per  cent. 

Glycogen  is  most  easily  made  from  glucose  and  Isevu- 
lose;  less  so  from  galactose,  maltose  and  starch;  least 
easily  from  cane  and  milk  sugar. 

Fat  is  formed  from  sugar  by  the  subcutaneous  cells, 
which  are  especially  adapted  to  this  function. 

Sugar  is  oxidized  to  carbon  dioxide  and  water,  which 
can  be  measured  by  the  respiratory  metabolism.  Nor- 
mally, sugar  is  absorbed  from  the  small  intestines,  and 
is  not  found  in  the  feces. 

In  urine  very  minute  amounts  are  present,  when  pass- 
ing the  capacity  for  assimilation,  thereby  producing  an 
alimentary  glycosuria.  This  is  most  easily  accomplished 
in  the  following  order:  lactose,  galactose,  Isevulose, 
glucose. 

The  assimilation  limit  for  sugars  is  much  greater  in 
infants  than  in  adults.  An  infant  may  develop  mellituria 
when  milk  sugar  exceeds  3.1  to  3.6  grams  per  kilogram 
body  weight ;  in  the  adults  at  over  1  gram  per  kilogram. 
The  cane  sugar  limit  is  about  the  same  as  milk  sugar, 
while  that  of  malt  sugar  is  7.7  grams  per  kilogram  body 
weight.  The  height  of  the  assimilation  limit  in  itself 
shows  that  the  infant's  organism  is  adapted  to  a  higher 
carbohydrate  metabolism  than  that  of  the  adult. 

Carbohydrates  in  the  Tissues.  The  newborn  has  a  gly- 
cogen depot. 


METABOLISM    IN    INFANTS.  15 

Carbohydrates  can,  in  part  at  least,  replace  proteins 
and  fats.  They  cause  a  rapid  increase  in  weight  (very 
rapid  at  first),  being  deposited  in  the  tissues,  as  glycogen, 
which  latter  can  absorb  two  to  three  times  its  weight  of 
water. 

The  relation  of  fats  to  carbohydrates  is  as  follows : 

The  more  carbohydrates  present,  the  greater  is  the  ten- 
dency on  the  part  of  the  system  to  build  up  body  fats. 
As  to  oxidation  of  fats,  ''They  are  burned  up  in  the  fire 
of  carbohydrates"  (Naunyns). 

The  complete  burning  of  fats  into  carbon  dioxide  and 
water  takes  place  only  when  the  carbohydrate  metabolism 
is  normal ;  otherwise  we  get  as  mid-products  the  acetone 
bodies  (acetone,  aceto-acetic  acid,  oxybutyric  acid,  etc.). 
This  occurs  also  in  starvation.  (Important  in  infants' 
diseases,  as  seen  in  diabetes,  continued  fevers,  intoxi- 
cation, etc.). 

Acetone  bodies  can  also  be  formed  from  protein  mole- 
cules. This  occurs  in  starvation  and  in  meat  and  fat 
diets  (deficiency  of  carbohydrates  in  the  latter). 

Weight  becomes  stationary  or  a  loss  results  when  car- 
bohydrates are  excluded  or  insufficient  in  the  diet.  Tem- 
perature falls,  and  does  not  rise  to  normal  until  they  are 
replaced. 

4.  Salts.  Chemistry  of  Salts.  Salts  added  to  water 
are  relatively  split  into  their  "ions" — that  is,  into  either 
electrically  positive  or  negative  bodies.  A  solution  of 
sodium  chloride  is  a  solution  in  which  the  NaCl  molecule 
is  intact,  but  the  Na  (kation)  is  electro-positive;  the  CI 
(anion)  is  electrically  negative. 

Human  milk  contains  0.2  Gm.  ash  in  100  mils.  Cow's 
milk  0.75  Gm.  ash  in  100  mils.  Some  exists  as  inorganic 
salts,  others  as  important  organic  compounds. 


16      ,,  IXFAXT    FEEDING. 

I.  Rations  (or  cations). 

1.  Calcium. 

(1)  Human  0.42  Gm.  per  1000  mils,  cow's  1.72 

Gm.  per  1000  mils,  about  1 :  4.5. 

(2)  Excretion  is  almost  entirely  through  intes- 

tines, some  from  unabsorbed  food  rem- 
nants, and  the  rest  by  tissue  metabolism. 

2.  Magnesium. 

(1)  Human   0.068   Gm.   per   1000   mils,   cow's 

0.2  Gm.  per  1000  mils. 

(2)  Its  metabolism  is  very  closely  related  to  the 

calcium. 

3.  Sodium.     4.  Potassium. 

(Ij   Human  milk  0.16  Gm.  XaoO,  cow's  0.465 
Gm.  Xa20  per  1000  mils,  1  :  3. 

(2)  Human  milk  0.69  Gm.  KoO,  cow's   1.885 

Gm.  KoO  per.  1000  mils,  1 :  3. 

(3)  Excretion    mostly    through     kidneys    and 

stools. 
5.  Iron. 

Human  milk  0.001  to  0.004  Gm.  cow's  0.0007 
Gm.  per  1000  mils.  These  figures  show 
considerable  variation  according  to  dif- 
ferent authors.  Excreted  mainly  through 
the  bowels. 
XL  Anions. 
1.  Chlorine. 

Human  0.294  Gm.,   cow's  0.82   Gm.   per   1000 
mils,  1 :  3. 

(1)  Absorption:    90  to   100  per  cent,  through 

the  intestine. 

(2)  Excretion:    mostly  through  kidneys. 

(3)  About  0.5  per  cent,  retained  by  the  system. 


METABOLISM    IX    INFANTS.  17 

2.   Phosphorus  is  contained  in  the  milk  in  the  fol- 
lowing forms : 

(1)  Inorganic   (calcium  phosphate). 

(2)  Organic  (casein,  nuclein,  lecithin,  etc.). 

(3)  Total  in  human  0.294  to  0.418  Gm.,  in  cow's 

2.437  Gm.  per  1000  mils,  1 : 9. 

(4)  Organic  in  human  43.3  per  cent.,  and  cow's 

46  per  cent.,  1:1. 

(5)  The  retention  is  higher  in  artificially  fed 

than  those  fed  on  human  milk. 

Relation  of  Salts  to  Metabolism.  The  salts  are  neces- 
sary in  digestion  and  in  every  step  of  metabolism  from 
absorption  to  excretion  and  secretion.  The  role  of  these 
salts  in  both  normal  and  pathological  conditions  has  been 
given  constantly  increasing  importance  in  the  last  few 
years. 

Metabolism  of  Salts  in  Infants.  In  the  gastro-intes- 
tinal  tract  the  foods  and  salts  are  constantly  changing 
action. 

A  casein  product  and  calcium  combine  in  the  stomach 
to  form  calcium  paracasein. 

Fatty  acids  and  alkalies  and  earthy  alkalies  in  the  intes- 
tines form  soaps. 

Casein  increases  excretion  of  salt  in  the  intestine 
(moderate). 

Fat  increases  excretion  of  salts  in  the  intestines 
(markedly,  especially  Ca,  Na,  K).  At  the  same  time  the 
phosphorus  excretion  decreases  as  the  calcium  phosphates 
are  changed  to  calcium  soaps  by  combination  of  calcium 
with  fatty  acids,  and  the  free  phosphoric  acid  unites  with 
sodium  and  potassium  to  form  easily  absorbed  salts. 

Salts  are  excreted  in  the  urine  and  stools.  The  stools 
are  the  main  source  of  excretion  of  calcium,  magnesium. 


18  INFANT   FEEDING. 

and  iron.  \Miether  these  are  formed  from  the  tissues  or 
unabsorbed  food  is  difficult  to  decide.  The  difference  in 
percentages  in  human  and  cow's  milk  is  equalized  by  the 
body  using  only  what  is  necessar)'  to  its  life  and  growth 
and  not  attempting  to  use  it  all. 
Functions  of  Salts. 

(1)  They  furnish  building  material  for  new  cells. 

(Rachitis  due  to  lack  of  absorption.) 

(2)  They  are  necessary  to  nerve  excitability,  muscle 

contraction,  and  many  other  vital  functions. 

(3)  Addition  of  calcium  and  potassium  to  normal 

salt  solutions  counteracts  their  poisonous 
eitects. 

(4)  Life  is  incompatible  with  withdrawal  of  min- 

erals or  even  one  ion. 

(5)  Life  does  not  so  much  depend  upon  the  ion  as 

on  its  chemical  combination.  Therefore  ash 
alone  will  not  supply  the  needs. 

(6)  Infants  need  minerals  for  growth,  as  well  as 

for  life.  Different  tissues  require  different 
amounts  and  different  salts. 

(7)  Weight  drops  with  withdrawal  of   salts,   even 

if  other  ingredients  are  constant,  due  to  loss 
of  water.  Sodium  salts  are  most  important 
in  water  retention,  calcium  salts  are  least. 

(8)  Temperature   falls,  when   salts  are  withdrawn 

(sodium). 

(9)  Phagocytosis  is  increased  by  calcium  salts.     Of 

value  in  infection. 

5.  Water.  Infants  need  105  Gm.  of  water,  and  adults 
40  Gm.  of  water,  per  Kg. 

Metabolism  of  Water.  Intake  is  in  the  food.  The 
outgo  from  the  kidneys,  bowels,  lungs,  and  skin. 


METABOLISM    IN    INFANTS.  19 

Water  when  ingested  quickly  passes  through  the  stom- 
ach to  be  absorbed  by  the  intestines.  The  water  content 
of  the  organism  varies  with  age  and  food.  In  the  adult 
58  per  cent,  of  body  is  water,  and  in  the  newborn  infant's 
body  66  to  69  per  cent,  is  water.  Sodium  salts  have  the 
greatest  facility  for  water  retention. 

Of  the  anions,  CI  is  the  most  marked  in  causing  water 
retention. 

Excretion  of  water  takes  place  as  follows :  kidneys  59 
per  cent.,  skin  and  lungs  33  per  cent.,  intestines  6  per 
cent.     One  to  2  per  cent,  of  the  water  intake  is  retained. 

Relation  of  Water  to  Metabolism.  Approximately 
two-thirds  of  the  body  is  water.  All  cells  need  it ;  it  is 
necessary  to  different  combinations  and  reactions.  In 
general,  it  is  necessary  for  young  infants  on  artificial 
feeding  to  receive  about  140  to  150  mils  (4  to  5  ounces) 
per  kilogram  (2  pounds)  body  weight  every  twenty-four 
hours. 

It  carries  nutritious  material  in  the  blood,  lymph,  cells, 
etc.,  and  also  the  material  for  anabolism  and  katabolic 
products. 

It  is  also  necessary  to  the  function  of  the  lungs  and  of 
the  skin. 

It  is  deeply  involved  in  the  question  of  immunity. 

6.  Lipoids.  Lecithin.  Lecithin  is  the  fatty  acid  ester 
of  the  glycerophosphates  (glycerin  phosphoric  acid). 
Human  milk,  0.499  Gm.  per  1000  Gm. ;  cow's,  0.63  Gm. 
per  1000  Gm.  The  organism  can  apparently  live  without 
it  in  its  food. 

Cholesterin.  Human  milk,  0.25  to  0.38  Gm.  per  1000 
Gm.     Mainly  excreted  by  the  intestines. 

Lecithin  and  cholesterin  belong  to  the  group  of  the  so- 
called   lipoids,   the   substances    which   according   to    our 


20  IXFAXT    FEEDIXG. 

present  knowledge  play  a  very  important  role  in  the  life 
of  the  cell.  Alice  die  if  their  food  is  made  free  from  all 
lipoids.  This  is  of  interest  when  we  consider  that  fat- 
free  milk  contains  but  little  lipoids. 

3.  Milk  Digestion. 

1.  In  the  Mouth.  In  the  mouth  milk  is  mixed  with 
saliva,  each  100  mils  of  milk  averaging  about  5  mils  of 
saliva  (Tobler).  The  secretion  of  saliva  is  stimulated 
mainly  by  the  act  of  sucking,  but  also  in  part  by  appetite 
(psychic  reflex).  Ptyalin  begins  its  action  on  the  carbo- 
hydrates of  the  milk.  Saliva  may  also  cause  coagulation. 

2.  In  the  Stomach.  In  the  stomach  the  milk  is 
curdled,  casein  being  precipitated  by  rennin.  Human 
milk  coagulates  less  rapidly  and  less  completely  than 
cow's  milk.  Therefore  in  the  latter  the  curds  and  the 
whe}'  are  more  quickly  separated. 

Proteins  are  changed  to  albumoses  and  peptones  by 
pepsin,  and  thus  they  are  prepared  for  further  digestion 
in  the  intestine.  Albuminous  digestive  products  stimu- 
late gastric  secretion. 

Of  fats  2h  per  cent,  are  changed  to  fatty  acids  and 
glycerin  by  lipase  and  action  of  bacteria.  Fats  at  first 
retard,  and  later  increase,  the  gastric  secretion. 

Action  of  ptyalin  on  carbohydrates  is  continued  during 
the  alkalinity  of  the  stomach. 

Absorption  in  the  stomach  is  as  follows:  (1)  salts  and 
sugars,  (2)  proteins  (small  amounts),  (3)  water  (none), 
(4)   fats   (none). 

Shortly  after  beginning  of  the  nursing  some  of  ^he 
whey  content  of  the  food  begins  to  leave  the  stomach. 
This  is  more  especially  true  if  the  ferments  are  active. 


METABOLISM    IN    IXI'AXTS.  21 

The  time  also  varies  with  tlie  (tuahty  of  the  meals. 
Human  milk  leaves  the  stomach  in  ahout  one  and  one- 
half  to  two  hours  after  ingestion,  and  cow's  milk  in  ahout 
three  hours  after  ingestion.  Two  factors  have  an  inijiior- 
tant  bearing  on  this  point:  (1)  the  quantity  of  the  fat, 
which  delays  the  passage  of  the  food  through  the  pylorus, 
(2)  the  size  of  the  curds,  the  large  curds  of  the  cow's 
milk  delaying  emptying  of  the  stomach. 

As  previously  stated,  whey  quickly  passes  out  of  the 
stomach,  and  remaining  curd  is  digested  at  the  surface, 
and  this  passes  over.  Solid  masses  may  pass  through. 
After  each  passage  of  food  the  pylorus  again  closes.  The 
rapidity  of  emptying  the  stomach  depends  on  the  action 
of  the  pylorus,  and  this  in  turn  on  the  chemical  composi- 
tion of  the  food.  Fats  and  albumins  remain  long  in  the 
stomach,  sugars  and  salts  passing  through  more  rapidly. 

3.  In  the  Small  Intestines.  The  action  of  the  gastric 
digestion  on  the  proteins  is  supplemented  by  trypsin  from 
the  pancreas,  and  the  erepsin  of  the  succus  entericus. 
End  products  of  the  protein  digestion  are  amino-acids. 
Carbohydrates  are  split  into  monosaccharides  in  the 
small  intestines  and  are  absorbed  there.  Fats  which  have 
been  split  into  fatty  acids  and  glycerin  are  emulsified  and 
absorbed.  Absorption  of  all  digested  food  is  almost 
complete  in  small  intestines.  It  may  be  stated  that  intes- 
tinal or  pancreatic  digestion  is  far  more  important  than 
gastric  digestion  in  the  infant. 

4.  In  the  Large  Intestines.  Absorption  of  water  and 
excretion  of  salts  are  the  chief  functions  of  the  large 
intestines  in  the  digestive  process. 

5.  Feces  and  Urine.  Feces  is  composed  of  food  rem- 
nants, products  of  secretory  activity  of  the  intestines, 
products  of  desquamation  of  the  intestines  and  bacteria. 


22  IXFAXT    FEEDING. 

Composition  of  feces  depends  to  a  certain  extent  upon  the 
nature  of  the  food  ingested.  Foods  rich  in  proteins 
(skim  milk,  albumin  milk,  etc.)  cause  increased  intes- 
tinal secretion,  with  resulting  alkaline  reaction,  which 
favors  putrefaction  and  furnishes  conditions  favorable 
for  development  of  fat  soap  stools.  Excess  of  carbohy- 
drates with  acid  fermentation  gives  another  picture. 
Putrefaction  and  fermentation  work  antagonistically  on 
the  reaction  of  the  stool.  There  is  a  balance  between  the 
acids  derived  from  fat  and  sugars  by  bacterial  action  and 
the  alkaline  intestinal   secretion. 

Proteins  in  the  stool  (giving  biuret  and  Millon's  tests) 
are  in  greater  part  not  derived  from  food  proteins,  but 
they  are  due  to  intestinal  secretions,  desquamated  epi- 
thelial cells  of  the  intestines,  and  to  the  bodies  of  bac- 
teria. This  is  especially  true  of  breast-fed  infants.  The 
normal  infant  stool  contains  no  unchanged  casein.  , 

Fat  has  important  influence  upon  the  formation  of  the 
stool.  On  feeding  with  human  milk  poor  in  fat  the 
stools  are  small,  containing  small  quantities  of  solids  and 
some  mucus.  On  feeding  with  human  milk  which  is  rich 
in  fat,  normal  stools  are  produced.  ^Microscopically  fat  is 
always  evident  in  stools,  and  is  derived  partly  from  food, 
and  in  small  quantities  from  the  secretion  of  intestinal 
juices.     Fatty  acids  and  fat  soaps  are  constantly  found. 

Salt  excretion  is  an  important  function  of  the  large 
intestine.  In  the  breast  fed,  ash  content  of  dry  stool  is 
10  per  cent.,  bottle  fed  40  per  cent.  Insoluble  calcium 
salts  harden  the  feces. 

The  following  are  some  tests  on  constituents  of  feces : 

1.  Fat  soap  easily  seen  as  fatty  acid  crystals  (needles) 
by  heating  with  acetic  acid  on  the  cover  glass  and  allow- 
ing to  cool. 


METABOLISM    IN    INFANTS.  23 

2.  Carbof uchsin  in  weak  solution  stains  as  follows : 
Neutral  fat :  no  stain.  Soaps :  faint  rose  color.  Fatty 
-acids:    red. 

3.  Sudan  IIL  stains  as  follows:  Neutral  fat:  orange 
red.  Soaps :  crystals  do  not  stain.  Fatty  acids :  stain 
red  or  crystals,  orange  red. 

4.  Sugar  is  not  demonstrable  in  any  quantity  as  such, 
but  the  character  of  the  fat  soap  stool  seen  in  milk  feed- 
ing without  sugar  is  changed  to  a  softer,  smaller,  and 
normal  color  by  adding  sugar. 

5.  Starch  is  demonstrable  by  iodine  test  microscopic- 
ally, but  care  must  be  exercised  in  the  interpretation  of 
the  test,  as  the  starch  may  be  derived  from  baby  powders. 

The  color  of  the  stool  is  due  to  bile  coloring  matter  de- 
rivatives :  bilirubin  and  its  reduction  products,  urobilin 
and  urobilinogen.  The  smaller  the  reduction  of  coloring 
matter  there  is  present,  the  more  colored  the  stools.  By 
marked  reduction  to  urobilinogen,  the  color  becomes  al- 
most white.  The  more  milk  and  cream,  i.e.,  fat,  in  the 
diet,  the  paler  the  feces.  The  so-called  soap  stool  is  due 
to  excess  of  fat  and  overfeeding  with  milk  or  cream,  and 
is  a  firm,  grayish,  putty-like  stool.  (See  Disturbed 
Metabolic  Balance.) 

Thin  watery  stools  must  always  be  taken  seriously. 
However,  the  same  cannot  be  always  said  of  green,  curdy 
stools,  which  are  not  infrequently  seen  in  thriving  breast- 
fed infants.  These  curds  are  almost  invariably  due  to 
fatty  acids  and  soaps. 

Normal  stools  of  breast-fed  infants  are  homogeneous, 
salve-like,  ochre-yellow  color,  acid,  and  of  sour  odor. 
Microscopically  may  be  seen  detritus  masses,  bacteria, 
few  neutral  fat  corpuscles,  and  fatty  acid  crystals. 

Normal  stools  of  bottle-fed  infants  vary  with  the  diet. 
One  can  frequently  tell  the  diet  by  the  appearance  of  the 


24  IXFAXT    FEEDING. 

stool.  On  milk  diet:  less  frequent,  usually  1  or  2  daily, 
firmer  and  drier,  usually  pale  yellow,  alkaline  and  of  foul 
odor.  Constipation  is  the  rule  in  babies  receiving  large 
quantities  of  milk  with  a  moderate  amount  of  carbohy- 
drates. Sugars  have  a  laxative  tendency  (fermentation). 
Excess  of  brown  color  may  be  caused  by  excesses  of 
malt  sugar.  Starches,  if  well  taken,  tend  to  constipate, 
in  large  amounts  they  tend  toward  an  acid  reaction  and 
an  aromatic  odor. 

Stari'ation  of  liiinger  stool  is  seen  on  a  very  limited 
diet,  as  minimum  amounts  of  milk,  tea,  cereal  water. 
The  stool  has  a  dark,  greenish-brown  color,  is  soft,  and 
composed  in  great  part  of  mucus,  and  appears  semi-trans- 
parent. This  mucus  may  lead  to  further  starvation 
through  mistaken  interpretation  of  its  meaning,  and  re- 
sult disastrously. 

In  the  past  it  was  taught  that  a  study  of  the  stools  gave 
one  definite  information  for  the  diflierential  diagnosis  of 
the  gastro-intestinal  disease,  but  experience  has  taught  us 
that  conclusions  are  of  value  only  when  based  upon  stool 
examinations  in  conjunction  with  a  careful  study  of  the 
diet,  and  clinical  examination  of  the  infant. 

Urine.  A  normal  infant  urinates  ten  to  fifteen  times 
daily,  and  the  urine  passed  represents  60  to  70  per  cent, 
of  the  fluids  taken  as  food  and  drink.  It  is  acid  in  re- 
action, and  should  be  free  from  albumin.  However,  al- 
bumin frequently  is  present  in  the  simple  nutritional  dis- 
turbances, and  almost  constantly  in  the  severe  acute  ill- 
nesses. The  temporary  presence  of  albumin  in  the  urine 
of  the  newborn  may  be  considered  physiological,  as  well 
as  the  uric  acid  during  the  very  early  stage.  Great  de- 
creases, even  to  anuria,  are  common  with  the  intestinal 
disturbances. 


CHAPTER    IV. 

BACTERIA    OF    THE    DIGESTIVE    TRACT 
OF    THE    INFANT* 

1.  The  Newborn. 

For  about  one  day  the  meconium  passed  by  the  new- 
born baby  is  sterile.  During  this  time,  however,  the  bac- 
teria begin  to  invade  the  digestive  canal  of  the  infant 
through  the  mouth  and  through  the  anus.  The  initial  in- 
testinal flora  which  thus  develops  is  subject  to  marked 
differences,  the  number  and  nature  of  the  bacteria  de- 
pending chiefly  upon  the  surroundings  of  the  infant,  and 
exhibits  no  characteristic  constant  findings. 

This  period  is  followed  by  gradual  transition  in  the 
nature  and  in  the  number  of  the  intestinal  bacteria,  until 
about  the  third  day  after  birth  characteristic  intestinal 
flora  becomes  established,  constituting  chiefly  of  Bacillus 
bifidus  (in  the  nursing  infant)  and  Bacillus  coli  fin  the 
artificially  fed  infant),  and,  besides  these,  Bacillus  acido- 
philus, ^Micrococcus  ovalis,  Bacillus  lactis  aerogenes  and 
others. 

2.  The  Nursing  Infant. 

The  principal  portal  of  entry  of  the  intestinal  bacteria 
is  the  mouth.  There  is  no  doubt  that  a  great  variety  of 
organisms  may  from  time  to  time  enter  this  atrium,  in- 


*  In  the  elaboration  of  this  chapter  free  use  has  been  made  of 
A.  I.  Kendall's  Bacteriology,  Lea  &  Febiger.  Philadelphia  and 
New  York,  1916. 

(25) 


26  IXFAXT    FEEDING. 

eluding  not  only  the  ordinary  organisms  of  the  nursling's 
environments,  but  pathogenic  bacteria  as  well.  A  major- 
ity of  these  pass  to  the  stomach,  and  they  may  pass  to  the 
intestinal  tract. 

The  flora  of  the  mouth  and  of  the  stomach  are  not 
well  known,  but  they  appear  to  be  of  relatively  slight 
importance  as  a  rule. 

The  duodenal  flora  in  health  is  composed  chiefly  of 
coccal  forms  of  the  ^Micrococcus  ovalis  type.  Bacillus  coli 
and  other  members  of  the  colon  group  are  most  numer- 
ous at  the  ileocecal  valve  and  the  cecum,  and  Bacillus 
bifidus  or  similar  organisms  dominate  the  large  intes- 
tines from  this  level  to  the  sigmoid  flexure.  The  re- 
mainder of  the  large  intestines  to  the  rectum  is  some- 
what sparsely  populated  with  living  bacteria,  partly  be- 
caus,e  the  fecal  mass  is  relativelv  desiccated  bv  the  ab- 
sorption  of  water,  partly  because  of  the  accumulation  of 
waste  products  of  bacterial  activity — principally  acids  re- 
sulting from  fermentation  of  lactose,  formed  higher  up 
in  the  tract — which  inhibit  the  development  of  bacteria 
in  the  lower  levels. 

Bacillus  bifidus  (Gram  positive,  blue  stain)  predomi- 
nates in  the  intestinal  flora  of  the  breast-fed  infant,  being 
acid  tolerant  and  finding  favorable  conditions  for  its 
growth  and  development,  since  in  digestion  of  mother's 
milk  lactic  acid  production  from  lactose  is  so  great  as  to 
inhibit  the  growth  of  the  Bacillus  coli  and  Bacillus  lactis 
aerogenes  in  the  lower  end  of  the  ileum,  while  the  highly 
acid  medium  favors  the  growth  of  the  Bacillus  bifidus 
communis  and  the  acidophile  bacteria.  Coccal  forms  and 
lactose  fermenting  organisms  are  present,  but  scanty ; 
spore  bearers  are  rare. 


feACTERlA    OF    THE    DIGESTIVE    TRACT.  27 

3.  Artificially  Fed  Infants. 

Escherich  directed  attention  to  the  striking  dissimilar- 
ity between  the  intestinal  flora  of  the  breast  fed  and  the 
artificially  fed  infant.  Culturally,  morphologically,  and 
chemically  the  former  is  more  uniform  than  the  latter. 
The  most  distinctive  features  of  the  dejecta  of  the  arti- 
ficially fed  infants  are :  the  relative  increase  of  Gram- 
negative  bacteria  of  the  coli-aerogenes  type,  and  of  coccal 
forms  of  the  Micrococcus  ovalis  type,  together  with  a 
diminution  of  Bacillus  bifidus.  Bacillus  acidophilus  is 
relatively  more  numerous,  as  a  rule,  in  the  artificially 
fed  infant  than  in  the  nursling.  Proteolytic  bacteria  of 
several  types  are  also  of  frequent  occurrence,  but  they 
are  not  commonly  found  in  the  dejecta  of  the  normal 
nursling.  These  organisms  are  frequently  spore-form- 
ing bacilli,  of  which  two  principal  groups  are  recognized 
— members  of  the  aerobic  group,  of  which  Bacillus  mesen- 
tericus  is  a  prominent  type,  and  anaerobic  bacteria.  Of 
the  latter,  Bacillus  aerogenes  capsulatus  is  most  wndely 
known;  it  frequently  occurs  in  small  numbers  in  the 
feces  of  artificially  fed  infants.  The  reaction  of  normal 
feces  of  artificially  fed  babies  is  usually  alkaline ;  cul- 
turally and  chemically,  the  evidence  of  intestinal  proteo- 
lysis of  bacterial  causation  is  more  marked  in  these  in- 
fants than  in  normal  nurslings. 

The  general  distribution  of  types  of  bacteria  at  the 
different  levels  of  the  intestinal  tract  is  similar  to  that 
observed  in  normal  nurslings.  The  principal  differences 
are  found  in  the  cecum  and  large  intestine,  where  the 
obligately  fermentative  bacteria  of  the  bifidus  type  are 
replaced  to  a  considerable  degree  by  an  extension  of 


28  INFANT    FEEDING. 

habitat  of  the  Bacillus  coli,  of  Bacillus  acidophilus,  and 
the  appearance  of  moderate  numbers  of  proteolytic  bac- 
teria, both  aerobic  and  anaerobic ;  many  of  the  latter  are 
sporogenic. 

The  characteristic  feature  of  the  normal  adult  fecal 
flora  as  compared  with  the  infantile  nursling  flora  is  the 
very  heterogeneous  variety  of  types  of  bacteria  in  the 
former,  in  sharp  contrast  to  the  homogeneity  of  types  of 
bacteria  in  the  latter. 

4.  Significance  of  the  Intestinal  Bacteria. 

The  striking  differences  in  morphology,  chemistry,  and 
in  cultural  characters  between  the  intestinal  floras  char- 
acteristic respectively  of  nurslings,  artificially  fed  infants 
and  adults  suggest  at  once  that  nutritional  stimuli  may  be 
an  important  factor  in  determining  the  dominance  of 
type  of  bacteria.  It  is  probable  that  the  significance  of 
the  intestinal  flora  lies  rather  in  its  potential  antagonism 
to  alien  bacteria,  which  certainly  gain  entrance  to  the 
alimentary  canal  from  time  to  time,  than  in  any  specific 
participation  in  the  normal  digestive  process  of  the 
host. 

The  normal  intestinal  flora  may  be  regarded  as  intes- 
tinal parasites,  just  as  the  various  bacteria  which  occur 
commonly  on  the  skin  are  regarded  as  cutaneous  para- 
sites. It  is  important  to  realize  that  the  normal  intestinal 
organisms,  like  the  cutaneous  organisms,  are  "oppor- 
tunists," potentially  capable  of  becoming  invasive  when- 
ever the  barriers  which  ordinarily --suffice  to  limit  their 
development  to  the  lumen  of  the  alimentary  canal  become 
impaired,  giving  rise  to  endogenous  infections. 


BACTERIA    OF   THE    DIGESTIVE    TRACT.  29 

5.  Influence  of  the  Diet  on  the  Intestinal  Flora. 

Intestinal  flora  varies  greatly,  the  most  important  fac- 
tor in  determining  its  nature  being  the  chemical  compo,si- 
tion  of  the  food.  Human  milk  gives  essentially  different 
flora  from  cow's  milk.  There  are  two  groups  of  bacteria 
possessing  an  antagonistic  action,  those  causing  fermen- 
tation (saccharolytic),  and  those  causing  putrefaction 
(proteolytic).  The  representatives  of  the  former  are  Bac- 
illus lactis  aerogenes  and  Bacillus  bifidus,  the  latter  being 
the  most  important  organism  in  the  stool  of  the  breast-fed 
infants.  The  group  exercising  proteolytic  activity  is  less 
clear.  We  know  only  that  in  the  processes  of  putrefac- 
tion the  bifidus  flora  is  replaced  by  the  coli  group.  De- 
pending on  the  predominating  group  of  bacteria,  putre- 
faction or  fermentation  takes  place,  causing  either  firm 
or  soft  stools,  this  rather  than  the  activity  of  the  ferments 
determining  the  nature  of  the  stools.  The  nature  of  the 
food  and  its  chemical  composition,  therefore,  determines 
the  nature  of  the  development  and  activity  of  the  par- 
ticular bacteria  in  the  intestinal  tract. 

=The  human  milk,  rich  in  sugar  and  low  in  protein,  leads 
to  the  flora  of  fermentation,  while  cow's  milk,  rich  in 
protein  and  poor  in  sugar,  to  the  flora  of  putrefaction. 
This  phenomenon  is  nothing  specific,  but  is  due  to  in- 
dividual components  of  the  milk  and  their  mixture. 

Carbohydrates  lead  to  the  development  of  the  fermen- 
tative organisms ;  the  split  products  of  carbohydrates  are 
acetic,  butyric,  lactic  and  carbonic  acids. 

The  nature  of  the  dominant  organisms  which  develop 
in  diets  rich  in  carbohydrates  varies  with  the  carbohy- 
drate itself.  Bacillus  bifidus  is  more  commonly  predom- 
inant when  lactose  is  the  sugar  fed,  without  an  excess  of 


30  INFAXT   FEEDING. 

protein.  If  maltose  or  dextrose  is  substituted  for  lactose 
under  the  same  conditions,  Bacillus  acidophilus  is  very 
frequently  the  more  prominent. 

•The  fermentative  action  is  increased  by  sodium  and 
potassium  salts  as  found  in  whey.  (This  latter  probably 
in  part  explains  the  results  obtained  in  feeding  malt 
sugars  together  with  potassium  carbonate.) 

Proteins  favor  the  development  of  the  organisms  of 
putrefaction  and  lead  to  formation  of  indol,  skatol,  and 
amino-acids,  these  being  the  products  of  aromatic  and 
fatty  series.     Gases  are  also  formed  by  the  latter  action. 

The  nature  of  the  protein  influences  the  types  of  pro- 
teolytic bacteria  to  a  very  marked  degree.  In  general, 
animal  proteins  other  than  casein  appear  to  encourage 
somewhat  more  active  proteolytic  flora  than  vegetable 
proteins. 

The  processes  of  putrefaction  are  favored  by  calcium 
salts. 

The  influence  of  fat  in  its  relation  to  bacterial  proc- 
esses is  not  clear.  It  seems  to  be  able  to  favor  fermenta- 
tion, if  this  be  already  present,  and  also  to  increase  the 
intensity  of  the  processes  of  putrefaction. 

In  breast  feeding  fermentation  outweighs  putrefaction. 
The  question  whether  fermentation  or  putrefaction  in 
the  intestinal  canal  is  desirable,  must  be  answered  a  priori 
that  the  fermentative  processes  are  physiological,  since 
breast  feeding  always  leads  to  this.  By  this  it  must  not 
be  understood  that  the  putrefaction  in  artificial  feeding 
causes  injury.  Excessive  intestinal  fermentation  in  ar- 
tificial feeding  may  be  the  forerunner  of  disaster,  and  is 
to  be  avoided  (dyspepsia,  intoxication). 

Within  certain  limits,  we  are  able  to  influence  the  bac- 
terial processes  in  the  intestinal  tract  in  the  normal  infant, 


BACTERIA    OF   THE    DIGESTIVE    TRACT.  31 

and  thereby  change  the  character  of  the  feces.  In  a  sick 
infant  this  is  more  difficult,  and  larger  quantities  of 
putrefacient  food  are  necessary  to  overcome  pathological 
fermentation. 

6.  Intestinal  Bacteria  in  Their  Relation  to  Gastro- 
intestinal Disturbances. 

There  are  many  intestinal  disturbances  of  unknown 
causation,  presumably  unrelated  to  bacterial  activity. 
There  is  a  second  group  of  conditions  in  w^hich  bacteria 
may  conceivably  play  a  secondary  part;  in  some  of  the 
latter  abnormal  physiological  conditions  in  the  alimentary 
canal  may  be  justly  regarded  as  the  antecedent  factors. 
The  boundaries  of  these  two  groups  are  poorly  circum- 
scribed, and  they  merge  through  imperceptible  or  poorly 
defined  limits  into  a  third  group  of  cases  in  which  the 
activities  of  endogenous  or  exogenous  bacteria  in  the 
alimentary  canal  may  be  the  causative  factor  in  morbid 
processes  of  the  gastro-intestinal  tract. 

The  symptomatology  induced  from  the  products  aris- 
ing from  the  decomposition  of  proteins  or  protein  deriva- 
tives by  the  action  of  bacteria  in  the  intestinal  tract  de- 
pends largely  upon  the  organism  or  organisms  concerned. 
It  varies  from  the  somewhat  insidious,  slowly  progress- 
ing, so-called  autointoxication,  in  which  a  marked  in- 
crease of  urinary  ethereal  sulphates  may  be  a  suggestive 
index,  to  the  acute  toxemias  characteristic  of  bacillary 
dysentery,  typhoid,  paratyphoid  or  cholera.  Of  course, 
a  variety  of  other  bacteria  than  the  few  mentioned  speci- 
fically may  be  concerned,  either  alone  or  in  symbiosis. 
Thus  streptococci  alone,  and  streptococci  in  association 
with  dysentery  bacilli,  may  be  justly  regarded  as  the  etiol- 


o^ 


INFANT   FEEDING. 


ogical  agents  in  their  respective  syndromes.  The  im- 
portant factor,  from  the  viewpoint  of  this  discussion,  is 
to  reaHze  that  the  formation  of  nitrogenous  products 
from  proteins  or  protein  derivatives,  which  are  being 
utilized  by  various  types  of  intestinal  bacteria  for 
energy,  may  be  injurious  to  the  host. 

The  other  prominent  type  of  abnormal  bacterial  activ- 
ity in  the  alimentary  canal — the  fermentative  type — is  of 
entirely  different  origin.  The  essential  factor  is  either 
a  fermentation  of  carbohydrates,  with  the  formation  of 
products  abnormal  for  the  intestine,  or  of  excess  of  nor- 
mal fermentative  products.  The  factors  leading  to  an 
overgrowth  of  these  organisms  in  the  intestinal  tract 
appear  to  be  an  excess  of  carbohydrate  and  a  lack  of 
normal  lactic-acid-forming  bacteria. 

It  is  unfortunate  that  practically  none  of  the  bacteria 
which  incite  intestinal  disturbances  or  illnesses  produce 
soluble  toxins  against  which  antitoxins  can  be  prepared. 
Sera  likewise  have  been  unsatisfactory.  There  is  little, 
therefore,  that  can  be  accomplished  serologically  with  the 
present  methods  in  the  treatment  of  intestinal  disturb- 
ances of  bacterial  causation.  Attempts  to  permanently 
eliminate  or  destroy  undesirable  bacteria  with  cathartics 
and  intestinal  antiseptics  have  not  been  productive  of  re- 
sults in  the  past,  and  prolonged  starvation  per  se  does  not 
lead  to  intestinal  sterility  or  to  a  significant  reduction  in 
the  offending  bacteria. 

There  are  two  ways,  however,  in  which  direct  influ- 
ence may  be  applied  to  bacteria  in  the  intestinal  tract : 
by  substituting  harmless  types  of  organisms  for  abnormal 
types,  and  by  varying  the  diet  of  the  host  in  such  a  man- 
ner that  the  intestinal  contents  at  the  desired  level  shall 
contain  nutritive  substances  that  may  be  reasonably  ex- 


BACTERIA    OF   THE    DIGESTIVE    TRACT.  33 

pected  to  shift  the  metabolism  of  the  offending  organism, 
and  therefore  radically  change  the  character  of  the 
products  of  its  metabolism. 

Diseases  Due  to  Proteolytic  Activity  of  Bacteria. 
There  are  a  number  of  conditions  of  bacterial  causation 
in  which  available  evidence  points  strongly  to  the  forma- 
tion of  products  arising  from  the  metabolism  of  protein 
or  protein  derivatives  by  specific  organism  as  important 
etiological  factors  in  the  morbid  process.  Thus,  cholera, 
bacillary  dysentery,  typhoid,  paratyphoid,  and  many  less 
acute  infections  are  associated  definitely  with  the  de- 
velopment of  these  organisms  within  the  body,  and  to 
some  degree  at  least,  at  the  expense  of  the  body  tissues. 

Available  evidence  points  strongly  to  the  view  that 
cholera  vibrios,  typhoid,  dysentery  and  paratyphoid  bacilli 
and  similar  organisms  produce  their  characteristic  and 
harmful  effects  when  they  are  developing  in  media  free 
from  utilizable  carbohydrates ;  when  utilizable  carbohy- 
drates are  added  to  these  media,  non-characteristic,  harm- 
less products  are  formed. 

In  the  absence  of  any  definite  indication  to  the  con- 
trary, it  would  be  logical  to  attempt  to  maintain  a  suffi- 
cient concentration  of  carbohydrates  within  the  intestinal 
canal  in  these  infections  ag  a  therapeutic  measure. 

The  important  effects  to  be  accomplished  by  a  liberal 
carbohydrate  diet  in  those  infections  where  the  decom- 
position of  proteins  or  protein  derivatives  by  bacterial 
activity  leads  to  chronic  or  acute  illness  of  intestinal 
origin  are :  a  change  in  the  metabolism  of  the  offending 
organism  resulting  in  the  formation  of  lactic  and  other 
acids  in  them  in  place  of  putrefactive  products,  and  a 
gradual  replacement  of  the  proteolytic  and  pathogenic 
types  by  bacteria  of  the  fermentative  varieties. 


34  INFANT   FEEDING. 

Diseases  Due  to  Excessive  Fermentation  of  Carbohy- 
drates. Another  type  of  intestinal  disturbances  depends 
upon  an  unusual  or  an  excessive  fermentation  of  carbo- 
hydrates. This  is  frequently  seen  in  young  infants,  in 
many  of  whom  we  have  a  limited  carbohydrate  tolerance. 
(See  Nutritional  Disturbances.) 


Part  II. 

The    Nursing. 


CHAPTER    I. 

GENERAL  CONSIDERATIONS. 

Writers  on  this  subject  are  very  prone  to  state  that 
the  abiHty  of  the  mother,  particularly  among  the  well-to- 
do,  to  fulfil  this  most  important  function  is  decreasing. 
This  may  have  been  a  true  statement  fifteen  or  twenty 
years  ago.  At  the  present  time,  however,  we  are  sure  it 
is  erroneous.  The  young  mother  of  to-day  is  better  able 
to  nurse  her  offspring  than  was  her  sister  fifteen  or 
twenty  years  ago.  We  attribute  this  to  the  fact  that  the 
youth  of  the  present  day  are  more  vigorous,  more  nearly 
normal  individuals,  than  were  those  of  an  earlier  date. 
Breast-milk  during  the  first  two  or  three  weeks  of  the 
infant's  life  is  produced  under  unfavorable  conditions, 
which  do  not  indicate  the  possiblities  of  the  breast  as  a 
secreting  organ.  Early  nursing,  following  as  it  does 
upon  the  stress  of  confinement,  is  not  indicative  of  what 
may  be  possible  later,  when  the  customary  life  and  daily 
habits  are  resumed.  Repeatedly  we  have  found  a  very 
high  fat  or  a  high  protein,  or  both,  entirely  corrected 
after  the  first  week  or  two  without  interference.  This 
condition  at  the  time  was  considered  sufficiently  serious 
to  warrant  the  discontinuance  of  nursing  on  the  part  of 
a  weakly  infant,  while  in  a  vigorous  infant  it  would  be 
entirely  ignored.     A  neurotic  mother  makes  the  poorest 

(35) 


36  INFANT   FEEDING. 

possible  milk-producer.  Proportionate  to  the  popula- 
tion, there  are  fewer  neurasthenics  among  the  young 
women  to-day  than  there  were  twenty  years  ago,  and 
there  will  be  still  fewer  twenty  years  hence.  At  the 
present  time  the  timid,  retiring  young  woman  of  the 
neurasthenic  type  is  not  popular  in  her  set. 

Few  functions  with  w^hich  we  have  to  deal  are  so 
variable  and  uncertain  as  the  production  of  breast  milk. 
Breast  milk  is  one  of  the  most  precious  substances.  It 
is  invaluable,  unless  we  can  put  value  on  human  life. 
The  most  successful  nursing  age  is  between  the  twentieth 
and  thirty-fifth  year. 

Some  mothers  will  be  able  to  carry  on  the  nursing  for 
only  two  months,  others  three,  five,  seven,  or  nine 
months.  In  our  experience  in  both  out-patient  and  in 
private  practice  it  is  extremely  rare  for  the  breast  milk 
to  be  sufficient  for  the  infant  after  the  ninth  month. 

It  should  be  remembered  that  besides  the  protein,  fat, 
carbohydrate,  salts  and  water  content  there  are  other 
bodies  contained  in  human  milk,  which,  even  though  not 
essential  to  the  infant's  life,  are  of  inestimable  value 
to  it.     These  may  be  divided  into  two  groups : 

1.  Immunizing  bodies — antitoxins,  alexins,  etc. — 
which  are  contained  in  the  mother's  blood,  and  trans- 
mitted to  the  baby  through  her  milk.  They  are  of  value 
in  protecting  the  infant  against  infections. 

2.  Ferments :  lipase,  galactase,  lactokinase,  and  dias- 
tase. 

Examination  of  Human  Milk.  This  is  rarely  of  any 
practical  value.  The  protein  rarely  causes  trouble,  and 
the  sugar  is  usually  constant  (6  to  7  per  cent.).  The 
examination  of  milk  is  therefore  usually  restricted  to  a 
determination  of  the  fat  content  by  means  of  the  lacto- 


GENERAL   CONSIDERATIONS.  37 

meter.  The  richest  milk,  however,  will  usually  agree 
with  the  baby,  and  it  is  apt  to  thrive  equally  well  on  a 
milk  that  shows  a  small  amount  of  fat.  In  other  words, 
the  baby  and  not  the  lactometer  is  the  only  practical  test. 
If  the  milk  disagrees,  it  will  be  evident  clinically.  No 
baby  should  ever  be  deprived  of  its  mothei'^s  milk  only 
because  of  the  results  of  a  clinical  examination  of  the 
milk. 

In  making  an  examination  of  the  mother's  milk  one 
must  bear  in  mind  that  the  first  milk  is  very  poor,  the 
last  very  rich  in  fat,  and  that  an  average  specimen  can 
be  obtained  only  by  mixing  the  whole  amount,  or  by 
combining  the  first  and  the  last,  or,  better  still,  by  taking 
only  the  middle  portion  after  a  few  drams  have  been 
drawn  off.  This  can  be  accomplished  by  allowing  the  in- 
fant to  nurse  for  two  minutes  before  expressing  the 
sample. 

Contraindications  to  Nursing.  Tuberculosis  when 
progressive  or  open  is  always  a  contraindication  to  nurs- 
ing, because  of  the  danger  to  the  infant  and  the  strain  on 
the  mother.  With  proper  precautions,  and  where  the 
breast  is  not  diseased,  and  human  milk  is  not  obtainable 
from  other  sources,  it  may  be  well  to  tide  a  weak  infant 
over  its  first  weeks  by  expressing  the  milk  from  the 
mother's  breast. 

Syphilis  of  the  mother,  except  in  freedom  from  infec- 
tion on  the  part  of  the  infant,  is  not  a  contraindication. 
Lack  of  symptoms  on  the  part  of  the  mother  in  congeni- 
tal syphilis  is  a  very  common  occurrence ;  a  Wassermann 
reaction  on  the  mother's  blood  will  quickly  clear  up  any 
doubt. 

Any  grave  constitutional  disease  in  which  there  is  an 
extraordinary  drain  on  the  resources  of  the  body   (dia- 


38  INFANT   FEEDING. 

betes,  heart  disease  with  disturbed  compensation,  neph- 
ritis, Basedow's  disease,  maUgnant  neoplasms,  epilepsy 
and  psychoses)  are  contraindications  to  nursing. 

Acute  diseases  should  only  in  exceptional  cases  be  con- 
sidered as  contraindications  to  nursing,  and  should  in- 
clude conditions  in  which  there  is  danger  of  overburden- 
ing the  mother  and  infections  endangering  the  infant. 


CHAPTER    II. 

MATERNAL    NURSING. 

1.  Nursing  Axioms. 

The  following  may  be  laid  down  as  nursing  axioms : 

A  diet  similar  to  what  the  mother  was  accustomed  to 
before  the  advent  of  motherhood  should  be  taken. 

There  should  be  one  bowel  evacuation  daily. 

From  three  to  four  hours  daily  should  be  spent  in  the 
open  air  in  exercise  which  does  not  fatigue. 

At  least  eight  hours  out  of  every  twenty-four  should 
be  given  to  sleep. 

There  should  be  absolute  regularity  in  nursing. 

There  should  be  no  worry  and  no  excitement. 

The  mother  should  be  temperate  in  all  things. 

2.  Hygiene  of  the  Mother. 

The  Diet  of  the  Mother.  Many  times,  when  con- 
sulted by  nursing  mothers  because  the  nursing  was  un- 
successful or  a  partial  failure,  we  have  found  that  their 
diet  had  been  restricted  to  an  extreme  degree.  To  put 
on  a  greatly  restricted  diet  a  robust  young  mother  who 
has  always  eaten  bountifully  of  a  generous  variety  of 
foods  is  one  of  the  best  means  of  curtailing  the  quantity 
and  lowering  the  quality  of  her  milk  supply.  When 
asked  to  prescribe  a  diet,  we  tell  such  mothers  to  eat  as 
they  were  accustomed  to  before  the  advent  of  pregnancy 
and  motherhood.  That  this  particular  vegetable  or  that 
particular  fruit  should  be  forbidden  on  general  prin- 
ciples is  a  fallacy.    Food  that  the  patient  can  digest  with- 

(39) 


40  INFANT   FEEDING. 

out  inconvenience  is  a  safe  food  so  far  as  the  nursing  is 
concerned,  as  may  readily  be  determined  in  any  given 
case.  For  certain  individuals,  however,  a  plain,  more  or 
less  restricted  diet  is  desirable.  This  must  be  remem- 
bered in  the  management  of  the  wet-nurse  (to  be  de- 
tailed later). 

Nursing  is  a  perfectly  normal  function,  and  a  woman 
should  be  permitted  to  carry  it  out  along  the  natural 
lines.  Inasmuch  as  there  are  two  lives  to  be  provided 
for  instead  of  one,  more  food,  particularly  of  a  liquid 
character,  may  be  taken  than  the  mother  may  be  accus- 
tomed to.  It  is  our  custom  to  advise  that  milk  be  given 
freely.  A  glass  of  milk  may  be  taken  in  the  middle  of 
the  afternoon,  and  8  ounces  of  milk  with  8  ounces  of 
oatmeal  or  cornmeal  gruel  at  bedtime,  if  it  does  not  dis- 
agree with  the  mother.  Our  only  evidence  that  a  food  is 
disagreeing  is  the  condition  of  the  digestion.  When 
any  article  of  food  disagrees  with  the  mother,  or  if  she 
is  convinced  that  it  disagrees,  whether  or  not  such  be 
really  the  case,  the  food  should  be  discontinued.  In  a 
general  way,  milk  (one  quart  daily),  eggs,  meat,  fish, 
poultry,  cereals,  fresh  vegetables  and  fruits  constitute  a 
basis  for  selection.  Although  occasionally  mother  can- 
not take  acid  fruits,  salads  and  aromatic  vegetables,  they 
may  be  tried  and  discarded,  if  they  disturb  the  infant. 
Eggnogs,  thin  cereal  gruels  mixed  with  milk,  cocoa  and 
malted  milk  and  similar  drinks  can  often  be  taken  to 
advantage  between  meals. 

The  Bowel  Function.  A  very  important  and  often 
neglected  matter  in  relation  to  nursing  is  the  condition 
of  the  bowels.  There  must  be  one  free  evacuation  daily. 
For  the  treatment  of  constipation  in  nursing  women  we 
have  used  different  methods  in  many  cases.    The  dietetic 


MATERNAL   NURSING.  41 

treatment  and  plenty  of  recreation  and  exercise  promise 
most.  Manipulation  of  the  diet  should  not  be  such  as 
to  interfere  with  the  milk  production.  Three  other 
methods  are  open  to  use :  massage,  local  measures  and 
drugs.  Massage  is  available  in  comparatively  few  cases. 
Local  measures  consist  in  the  use  of  enemas  and  sup- 
positories. Every  nursing  woman  under  our  care  is  in- 
structed to  use  an  enema  at  bedtime,  if  no  evacuation  of 
the  bowels  has  taken  place  during  the  previous  twenty- 
four  hours.  For  a  laxative  in  such  cases  and  in  many 
others,  a  capsule  of  the  following  composition  has  served 
well: 

I^  Extract!  nucis  vomicce 0.015  Gm.   (J4  gr.). 

Extract!  cascarse  sagradse 0.325  Gm.   (v  gr.). 

Sig. :    To  be  taken  at  bedtime. 

The  amount  of  the  cascara  sagrada  may  be  varied  as 
the  case  may  require.  In  not  a  few  instances  we  have 
found  it  necessary  to  give  2  capsules  a  day  in  order  to 
produce  the  desired  result.  Neither  the  nux  vomica  nor 
the  cascara  appears  to  have  any  appreciable  efifect  on  the 
child. 

Air  and  Exercise.  Outdoor  life  and  exercise  are  not 
only  as  desirable  here  as  they  are  under  all  other  con- 
ditions, but  to  the  nursing  woman,  with  her  added  re- 
sponsibility, they  are  doubly  valuable.  In  order  to  get 
the  best  results,  exercise  or  work  should  be  so  adjusted 
as  not  to  reach  the  point  of  fatigue.  The  mother  whose 
nights  are  disturbed  should  be  given  the  benefit  of  a 
midday  rest  of  an  hour  or  two.  It  should  be  our  duty, 
however,  to  explain  to  the  mother  and  to  other  members 
of  the  family  that  an  important  element  in  satisfactory 
nursing  is  a  tranquil  mind. 


42  INFANT   FEEDING. 

Care  of  the  Breasts.  A  well  established  routine  should 
be  instituted  for  the  care  of  the  breasts.  To  facilitate 
this  a  readily  accessible  tray  with  the  necessary  utensils 
should  be  provided.  This  should  contain  a  glass-stop- 
pered bottle  with  a  saturated  solution  of  boric  acid,  a 
jar  of  cotton  pledgets  on  toothpicks,  to  be  used  as  appli- 
cators for  the  boric  acid,  a  graduated  glass  or  beaker. 
The  nipples  should  be  thoroughly  washed  before  and 
after  nursing  with  a  saturated  solution  of  boric  acid 
poured  fresh  from  the  bottle  for  each  cleansing,  and  the 
surplus  thrown  away.  The  boric  acid  should  be  applied 
with  the  cotton  pledgets.  The  fingers  should  not  come 
in  contact  with  the  nipples,  if  the  child  is  to  nurse  directly 
at  the  breast.  If  the  nipples  are  tender,  they  should  be 
annointed  with  a  sterile  mixture  of  5  per  cent,  tincture 
of  benzoin  in  liquid  vaseline. 

All  utensils,  including  the  breast-pump,  if  one  is  in 
use,  should  be  sterilized  by  boiHng.  In  case  of  the  breast- 
pump,  the  rubber  bulb  may  be  removed  for  this  purpose. 
Where  the  milk  is  to  be  expressed  by  hand,  the  hands 
must  be  thoroughly  disinfected  by  washing  with  soap 
and  water,  and  rinsing  with  alcohol  before  manipulation 
of  the  breasts.  Under  all  conditions  soap  and  water 
should  be  freely  accessible,  and  their  use  required  before 
handhng  the  breast  or  the  infant. 

3.  Conditions  Influencing  the  Breast  Milk. 

The  advent  of  the  first  menstruation  period  particu- 
Tarly,  and  in  some  cases  the  beginning  of  every  men- 
struation period,  is  attended  with  an  attack  of  colic  or 
indigestion  in  the  child.  Such  attacks,  however,  rarely 
necessitate  the  discontinuance  of  the  nursing  even  for 


MATERNAL   NURSING.  43 

a  single  day.  Not  infrequently  the  quantity  of  milk  is 
somewhat  lessened  during  menstruation,  and  this  will  re- 
sult in  the  infant  becoming  fretful,  due  to  insufficient 
quantity  of  the  feeding.  Under  no  circumstances  should 
menstruation  be  considered  an  indication  for  weaning. 

Factors  influencing  the  mental  condition  of  the  mother, 
such  as  anger,  fright,  worry,  shock,  distress,  sorrow,  or 
the  witnessing  of  an  accident  may  affect  the  milk  secre- 
tion sufficiently  to  cause  no  little  discomfort  to  the  child, 
and  oftentimes  the  lessening  of  the  flow  for  a  day  or 
two.  At  times,  especially  when  the  mother  is  under  in- 
fluence of  shock  or  grief,  it  may  be  necessary  to  substi- 
tute artificial  feeding  for  a  few  nursings  during  these 
periods,  until  the  mother  has  again  resumed  her  mental 
equilibrium,  her  breast  being  emptied  by  mechanical 
means  in  the  meantime. 

Drugs,  alkaloids  of  opium,  hyoscyamus,  belladonna, 
and  similar  drugs,  when  given  in  large  quantities,  not  in- 
frequently pass  into  the  milk,  and  should  therefore  never 
be  administered  in  large  quantities  to  the  nursing  mother. 
Belladonna  may  cause  a  decrease  in  milk  secretion,  and 
should  be  administered  with  caution  during  the  period  of 
lactation.  Mercury,  iodides  and  the  newer  salts  of  ar- 
senic are  also  secreted  in  the  milk,  and  may  be  used  to 
advantage  when  a  luetic  mother  is  nursing  a  luetic  infant. 

4.  The  Nursing  Proper. 

Regularity  in  Nursing.  The  breast  which  is  emptied 
at  definite  intervals  invariably  functionates  better  than 
does  one  which  is  not,  not  only  as  regards  the  quantity, 
but  also  the  quality,  of  the  milk,  thus  regular  habits  in 
breast-feeding  are  as  essential  to  milk  production  as  to 


44  INFANT   FEEDING. 

its  digestion  and  assimilation.  The  baby  should  be 
wakened  to  be  fed. 

The  average  mother  will  supply  the  needs  of  the  in- 
dividual meal  with  one  breast,  and  the  breasts  should  be 
alternated  in  successive  feedings.  Thorough  emptying 
of  the  breast  should  be  encouraged  under  all  circum- 
stances, as  this  is  our  best  method  for  increasing  the 
milk  supply,  and  the  baby  is  the  only  means  at  hand  by 
which  this  can  be  accomplished.  This  should  be  en- 
couraged in  every  instance.  It  is  most  readily  thwarted 
by  allowing  a  lazy  baby  to  partially  empty  both  breasts, 
and  will  soon  lead  to  a  diminished  milk  secretion.  By 
this  means  the  mother  and  the  baby  soon  become  adapted 
to  one  another,  and  it  will  be  found  that  the  desired  effect 
is  accompHshed  both  where  the  milk  supply  is  insuffi- 
cient or,  again,  excessive.  In  the  former  instance  com- 
plete emptying  of  the  breasts  increases  the  secretion,  and, 
where  excessive,  incomplete  emptying  will  soon  result  in 
a  lessened  supply. 

Sometimes,  however,  it  is  advisable  to  give  both  breasts 
at  each  feeding,  i.e.,  under  the  following  conditions:  (1) 
During  the  first  few  days,  to  stimulate  secretion,  and  a 
little  later  to  relieve  the  congested  breasts;  (2)  to  weak 
babies  when  there  is  an  abundance  of  milk,  and  they  are 
not  strong  enough  to  get  the  last  milk  that  comes  harder  ; 
(3)  to  overfed  babies,  where  it  is  desirable  to  give  them 
only  the  first  and  weakest  milk,  and  to  lessen  the  yield 
of  the  milk  from  the  breast ;  (4)  as  the  milk  supplied  by 
one  breast  fails  to  meet  the  needs  of  the  infant,  both 
breasts  should  be  given  at  each  nursing;  the  first  breast 
should  be  thoroughly  emptied  before  allowing  the  baby 
to  take  the  second  breast,  and  the  next  nursing  started 
on  the  second  breast  given  in  the  last  feeding. 


MATERNAL   NURSING.  45 

Number  of  Feedings  in  Twenty-four  Hours.  Four- 
hour  intervals  at  start  with  six  feedings  in  twenty-four 
hours,  five  feedings  by  the  second  to  the  fifth  month,  ac- 
cording to  the  individual  needs  of  the  child.  Night 
nursing  can  often  be  discontinued  by  this  time,  and 
babies  properly  fed  will  go  from  10  p.m.  to  6  a.m.  with- 
out anything  but  perhaps  a  drink  of  water. 

Premature  and  delicate  infants  and  infants  with  a 
tendency  to  vomit  are  exceptions,  and  must  be  fed  smaller 
amounts  at  more  frequent  intervals. 

Length  of  Nursing.  As  a  rule,  a  robust  baby  takes 
three-fourths  of  the  milk  obtained  from  a  good  breast 
in  the  first  five  minutes  of  a  twenty-minute  nursing. 
Fifteen  to  twenty  minutes  should  be  the  limit  for  the 
nursing  period.  If  a  baby  is  doing  well  on  shorter 
periods,  and  seems  satisfied,  let  it  be  its  own  judge  of  the 
nursing  time.  Weak  and  lazy  babies  may  require 
awakening  during  the  nursing  period  to  keep  them  at 
work.  Very  weak  babies  may  require  a  longer  period, 
with  short  intervals,  in  which  they  rest. 

Giving  of  Water.  From  ^  to  1  ounce  of  a  1  per  cent, 
solution  of  cane  or  milk  sugar  should  be  given  the  infant 
every  three  or  four  hours  until  the  milk  appears  in  the 
breast.  Otherwise  there  will  be  unnecessary  loss  of 
weight  and  perhaps  a  high  degree  of  fever  due  to  inani- 
tion. A  high  temperature  during  the  first  days  of  life  is 
more  commonly  due  to  ''inanition''  than  infection  in 
present-day  obstetrics.  The  best  differential  test  is  ad- 
ministration of  water  or  sugar-water  at  regular  intervals. 
In  a  case  of  inanition  plenty  of  fluid  intake  results  in  a 
critical  drop  in  the  temperature. 

If  the  child  is  restless  and  uncomfortable,  it  is  safe  to 
conclude  that  it  is  thirsty.    One  ounce  of  the  sugar-water 


46  INFANT   FEEDING. 

will  usually  satisfy  it.  With  the  commencement  of  nurs- 
ing, the  baby  should  be  accustomed  to  getting  the  food 
at  regular  intervals.  Even  when  milk  is  plentiful,  the 
administration  of  water,  two  or  three  times  daily,  from  a 
nursing  bottle  accustoms  the  baby  to  taking  the  food  in 
this  way.  This  makes  weaning  more  easy  in  case  of 
emergency. 


CHAPTER    III. 
WET-NURSING. 

1.  The  Wet-nurse:    Her  Selection  and  Her  Baby. 

The  Problem.  When  there  is  a  positive  inabiUty  on  the 
part  of  the  mother  to  nurse  her  offspring,  either  through 
improper  development  on  the  part  of  the  breast  or  sys- 
temic disease,  we  are  confronted  with  the  problem  of 
securing  human  milk  from  another  source,  as  notwith- 
standing the  numerous  reports  on  successful  raising  of 
infants  on  artificial  foods,  the  statistics  of  infants  fed  by 
artificial  foods  when  compared  with  those  of  infants  fed 
on  human  milk  are  so  strikingly  in  favor  of  the  latter 
that  the  obtaining  of  human  milk  must  always  be  con- 
sidered as  an  important  issue. 

How  Obtained.  In  our  experience,  even  in  a  large 
city,  great  difficulty  has  been  met  in  obtaining  a  regular 
supply  of  wet-nurses.  On  several  occasions  various 
charitable  and  hospital  societies  have  attempted  to  estab- 
lish a  wet-nurses'  registry  as  a  clearing-house  for  the 
several  maternity  and  general  hospitals  of  Chicago. 
These  attempts  have  not  been  successful  for  two  reasons : 
(1)  because  of  the  irregularity  in  the  demand,  and  (2) 
because  of  the  lack  of  co-operation  on  the  part  of  the 
various  institutions  caring  for  this  class  of  cases. 

The  Nationality  of  the  Wet-nurse  is  of  considerable 
significance  where  the  supply  allows  of  a  selection.  The 
phlegmatic  temperaments  as  seen  in  women  of  Northern 
and  Central  Europe  of  Teutonic  and  Slavic  descent, 
offer  the  ideal  material,  while  other  nationalities,  such  as 
Italians,  and  the  Southern  negroes  when  removed  from 

(47) 


48  INFANT   FEEDING. 

their  home  environment  to  a  Northern  dimate,  secrete  a 
milk  poor  in  quahty.  However,  even  the  latter  in  an 
emergency  should  not  be  neglected. 

Requirements  of  a  Good  Wet-nurse.  1.  She  should 
be  in  good  health,  and,  especially,  free  from  all  con- 
tagious and  infectious  diseases,  and  also  from  local  dis- 
eases of  any  kind,  such  as  those  involving  the  nose, 
throat,  skin,  etc. 

2.  Her  mammary  glands  should  be  of  such  quality  that 
she  can  secrete  sufficient  milk  of  good  quality,  and  the 
nipples  sufficiently  developed  to  allow  of  nursing,  or 
proper  expression  of  the  milk. 

3.  Whenever  possible,  her  age  should  be  not  less  than 
18  and  not  more  than  35  years. 

4.  The  age  of  her  baby,  as  compared  with  that  of  the 
baby  she  is  to  nurse,  is  a  matter  of  indiiTerehce  in  most 
instances.  However,  the  first  weeks,  or  if  possible  the 
first  two  months,  of  lactation  should  be  avoided,  because 
of  the  presence  of  colostrum  and  the  rapidly  changing 
quality  of  the  breast  milk,  which  not  infrequently  causes 
serious  gastric  and  intestinal  disturbances  in  very  suscep- 
tible infants,  as  evidenced  by  vomiting,  colic  and  diar- 
rhea. Multiparity  may  be  considered  an  asset,  if  the 
nurse  has  demonstrated  her  ability  to  care  for  and  feed 
previous  cases.  A  multipara  is  also  less  likely  to  be 
affected  by  her  new  surroundings,  especially  if  this  be  a 
private  home.  When  the  wet-nurse  has  more  or  less 
direct  charge  of  the  infant,  one  wdio  has  been  nursing 
her  own  or  other  infants  w411  be  more  likely  to  meet  the 
technical  difficulties  in  the  care  of  her  charge. 

Examination  of  the  Wet-nurse.  The  examination  of 
the  wet-nurse  should  always  be  made  in  a  systematic 
manner  to  insure  against  overlooking  important  things. 


WET-NURSING.  49 

First,  a  careful  history  should  be  taken  as  to  the  num- 
ber of  her  children,  miscarriages,  and  the  presence  of 
constitutional  diseases  in  her  family. 

Second,  she  should  be  thoroughly  examined,  all  parts 
of  the  body  being  exposed,  and  the  examination  should 
include  the  skin  and  hairy  parts  of  the  body  for  the  pres- 
ence of  skin  lesions  and  parasites,  as  well  as  for  old 
luetic  scars.  The  organs  of  the  chest  and  abdomen 
should  be  subjected  to  careful  examination. 

Third,  the  breasts  should  be  examined. 

Fourth,  the  genitalia,  including  the  cervix  and  the 
urethra,  and  in  all  cases  a  cervical  (and  where  sus- 
picious, a  urethral)  smear  should  be  taken  and  exam- 
ined for  gonococci.  As  a  single  smear  is  often  mislead- 
ing, in  cases  of  the  slightest  suspicion,  where  a  girl  baby 
is  to  be  nursed,  the  examination  of  the  cervical  and 
urethral  smears  should  be  repeated.  • 

Fifth,  an  examination  and  search"  should  be  made  for 
chronic  infections',  especially  for  syphilis.  A  Wasser- 
mann  test  should  be  made  in  every  case,  and  reported 
upon  before  she  is  allowed  to  supply  milk,  as  it  is  well 
known  that  a  syphilitic  mother  in  a  very  great  number  of 
cases  shows  no  clinical  evidence  of  syphilis.  The 
mouth  and  pharynx,  neck,  anus  and  genitalia,  entire  skin 
and  lymphatic  glands  should  also  be  examined  for  evi- 
dence of  syphilitic  lesions. 

Tuberculosis.  The  lungs,  glands,  and  osseous  system 
should  be  examined,  and  a  careful  history  as  to  suscep- 
tibility to  colds  and  to  recurring  bronchitis  elicited. 

Sixth.  Acute  infections.  She  should  be  questioned  as 
to  exposure  to  contagious  disease,  and  she  should  be  ex- 
amined   for   evidence   of   acute   infections   of   the   nose, 

throat,  and  ears. 

4 


50  IXFAXT    FEEDING. 

Seventh.  Her  teeth  should  be  examined  and  defects 
and  pyorrhea  corrected,  if  necessary,  at  the  expense  of 
the  family. 

Eighth.  The  urine  should  be  examined  (1)  for  evi- 
dence of  nephritis,  (2)  for  evidence  of  diabetes.  It 
should,  however,  be  remembered  that  a  positive  reaction 
for  sugar  should  not  be  overestimated,  unless  the  sugar 
is  proven  to  be  dextrose,  as  very  commonly  in  our  ex- 
perience during  the  early  weeks  of  lactation  a  lactosuria 
is  present.  The  kind  of  sugar  can  easily  be  determined 
by  the  phenylhydrazine  test,  followed  by  a  microscopical 
examination  of  the  crystals. 

Ninth.  Nervous  and  psychic  disturbances,  such  as 
epilepsy,  insanity,  hysteria,  should,  if  found,  by  all 
means  exclude  the  subject. 

Tenth.  Her  child  should  be  examined  for  evidence  of 
syphilis.  Possibly  one  of  the  best  arguments  for  the 
non-employment  of  a  wet-nurse  during  the  first  two 
months  of  her  lactation  is  the  possibility  of  a  latent 
syphilis.  Where  there  is  the  slightest  doubt,  a  Wasser- 
mann  reaction  should  be  made  on  the  infant.  The  gen- 
eral condition  of  the  child  gives  us  the  best  evidence  both 
as  to  the  quantity  and  to  the  quality  of  the  maternal  milk. 
Unless  the  source  of  the  nurse  be  known,  it  is  well 
to  be  certain  that  she  is  nursing  her  own  baby.  In  case 
of  its  death  or  its  absence,  every  effort  should  be 
made  to  obtain  its  condition  at  birth  and  its  later 
development. 

So  far  as  possible  she  should  not  be  subjected  to  an- 
noying questioning  on  the  part  of  the  family,  which  is 
entirely  unnecessary,  if  she  has  been  properly  examined 
by  the  physician.  It  has  been  our  experience  that  such 
unnecessary  questioning  has  led  to  nervousness,  and  not 


WET-NURSING.  51 

infrequently  has  caused  her  to  decline  the  position,  at  a 
time  when  she  was  most  needed. 

Her  Place  in  the  Household.  She  should  be  treated 
neither  as  a  guest  nor  as  a  menial,  but  so  far  as  possible 
should  be  graded  according  to  her  previous  station  in 
life.  There  is  a  grave  danger  of  mental  depression  on  the 
part  of  a  woman,  well-born  and  sensitive,  who,  through 
misfortune  or  necessity,  is  forced  to  seek  this  means  of 
employment,  and  also  of  an  exaggerated  estimate  of 
self-importance  on  the  part  of  a  woman  but  little  accus- 
tomed to  the  luxuries  of  life  upon  her  entrance  into  the 
home  of  employment,  particularly  if  attentions  are  paid 
to  her.  As  has  been  previously  stated,  all  instructions 
and  demands  should  be  made  by  the  person  best  qualified 
in  the  individual  case.  A  divided  responsibility  will 
always  lead  to  future  complications. 

Her  quarters  should  be  well  located ;  their  ventila- 
tion should  be  supervised,  and  she  should  be  held  re- 
sponsible for  their  general  cleanliness.  The  wet-nurse's 
baby  should  always  be  kept  in  the  room  with  her,  so  that 
she  may  feel  the  full  responsibility  for  its  health  and  care. 

The  Quantity  of  Milk  to  be  Expected  from  a  Good 
Wet-nurse.  The  quantity  and  quality  of  milk  supplied 
must  vary  greatly  with  the  glandular  development  of  the 
individual  wet-nurse,  the  state  of  her  health,  and  the 
factors  quoted  elsewhere  which  would  affect  it  tempor- 
arily. The  amount  and  variety  of  stimulation  applied  to 
the  breasts,  of  which  the  direct  n#rsing  by  a  full-term 
infant  is  the  most  valuable  (at  least  for  the  purpose  of 
stripping  the  breasts),  must  be  given  due  consideration. 
In  view  of  the  many  emergencies  and  influencing  factors, 
no  absolute  standard  for  quantity  and  quality  can  be  set 
for  general  rule. 


52  INFANT    FEEDING. 

A  wet-nurse  who  does  not  secrete  sufficient  milk  dur- 
ing the  first  few  days  in  her  new  employment  should  not 
be  discharged  until  every  effort  has  been  made  to  im- 
prove her  milk  production.  Frequently  the  change  in 
environment  is  sufficient  to  reduce  it  temporarily. 

Cost  of  Milk.  The  wet-nurses  in  Sarah  Morris  Hos- 
pital receive  their  board  and  room  and  $8.00  per  week. 
Figuring  the  former  at  $5.00  per  week,  this  would  total 
a  cost  to  the  institution  of  $13.00  per  week  for  each 
nurse.  With  an  average  of  30  to  40  ounces  of  milk  per 
nurse  daily,  or  210  to  300  ounces  per  week,  the  average 
cost  will  be  about  4.25  to  6.5  cents  per  ounce,  or  approxi- 
mately $1.35  to  $2.00  per  quart. 

When  milk  is  dispensed  to  patients  outside  of  the  hos- 
pital, a  charge  of  10  cents  an  ounce  is  made  for  it,  which 
is  a  reasonable  price  when  all  of  the  contending  factors 
are  taken  into  consideration. 

Number  of  Nurses  Needed.  Each  good  wet-nurse 
can  care  for  the  needs  of  about  two  infants,  depending 
upon  their  weight  and  development. 

Length  of  Lactation.  Xo  time-limit  is  placed  upon 
the  employment  of  a  wet-nurse  as  long- as  the  quality  and 
quantity  of  her  milk  is  sustained,  and  she  continues  in 
good  health.  One  of  our  nurses  has  an  infant  now  thir- 
teen months  old.  Such  long  periods  of  lactation,  how- 
ever, as  a  whole  are  not  to  be  advised. 

The  Wet-nurse's  Baby.  The  presence  of  the  w^et- 
nurse's  baby  predisposes  to  her  peace  of  mind,  and 
wherever  possible,  she  should  take  it  with  her.  Her 
baby's  state  of  health  is  by  all  means  the  best  indication 
as  to  her  ability  as  a  nurse,  and,  with  this,  the  presence 
of  constitutional  disease  in  herself.  It  may  be  of  im- 
mense value,  if  the  baby  is  strong  and  healthy,  to  keep 


WET-NURSING.  53 

up  the  flow  of  milk,  in  case  the  baby  to  be  nursed  is  a 
'weakhng.  It  may  also  be  used  to  estimate  the  functional 
capacity  of  a  wet-nurse  by  nursing  at  regular  intervals, 
and  weighing  before  and  after  the  nursing  for  twenty- 
four-hour  periods.  If  in  perfect  health,  it  may  be  put  to 
the  breast,  after  the  weakling  has  taken  such  milk  as  it 
has  strength  to  draw.  If  this  is  not  practicable,  then  the 
weakling  should  be  nursed  alternately  with  the  well  baby 
on  each  breast.  It  is  also  of  immense  value  in  emptying 
the  breast  after  the  wet-nurse  has  removed  ae  much 
milk  as  it  is  possible  by  expression  or  by  the  breast- 
pump,  if  this  is  the  means  of  drawing  the  milk  for  the 
weakling.  It  is  a  well-known  fact  in  all  institutions 
where  wet-nurses  are  used,  that  the  greater  the  degree 
to  which  the  breasts  are  stimulated  by  suckling  infants, 
the  greater  will  be  the  reward  in  production.  If  the  milk 
is  insufficient  for  both  babies,  partial  or  entire  meals  of 
artificial  food  may  be  substituted  for  the  wet-nurse's 
infant. 

At  the  first  sign  of  an  acute  illness  on  the  part  of  the 
wet-nurse's  baby,  it  should  be  separated  entirely  from  the 
other  baby,  and  removed  from  the  breast ;  its  illness 
should  be  given  the  same  serious  consideration  as  that  of 
the  other  infant,  so  that  the  mother's  anxiety  may  be  re- 
lieved. It  should  receive  as  much  of  its  mother's  milk 
as  can  be  spared.  This  can  be  expressed  from  the 
breasts  and  fed  from  a  bottle. 

Feeding  of  the  Wet-nurse's  Baby.  When  a  single 
infant  is  to  be  nursed,  the  second  baby  is  often  a  neces- 
sity in  the  promotion  of  the  development  and  stimulation 
of  her  breasts.  No  breast  can  be  developed  to  its  fullest 
capacity  with  the  breast-pump  or  hand  expressions.  It 
is  a  well-known  fact  that  the  breasts  will  respond  in  pro- 


54  IXFAXT    FEEDING. 

portion  to  the  demand  placed  upon  then,  and  in  most 
instances  during  the  first  few  weeks  of  the  premature's 
Hfe,  when  its  demands  are  met  by  from  4  to  16  ounces  of 
milk,  the  wet-nurse  can  supply  sufficient  milk  for  both 
babies.  When  her  supply  becomes  insufficient  to  meet 
the  demands,  her  baby  can  be  put  upon  partial  bottle 
feedings  of  the  strength  as  indicated  by  its  age  and  de- 
velopment. The  progress  of  the  wet-nurse's  baby  has 
great  influence  on  her  peace  of  mind,  which  may  spell 
success  or  failure  in  her  ability  to  carry  out  her  work. 
When  the  premature  infant  gives  evidence  of  sufficient 
strength  to  be  placed  upon  the  breast,  we  have  found  the 
application  of  the  wet-nurse's  baby  to  the  other  breast  a 
very  valuable  expedient  in  aiding  the  flow  of  milk  into 
the  breast  which  is  to  be  nursed  by  the  weakling.  In 
many  instances  we  have  seen  the  milk  flow  from  the 
second  breast  by  this  method  so  freely  that  but  very  little 
efl^ort  was  required  on  the  part  of  the  weakling  to  obtain 
its  food. 

2.  The  Hygiene  of  the  Wet-nurse. 

■  In  general,  everything  that  has  been  said  in  the  chap- 
ter on  hygiene  of  the  nursing  mother  applies  also  to  the 
wet-nurse — of  course,  with  the  proper  modifications, 
made  necessary  by  peculiarities  of  her  position. 

Her  clothes  should  be  simple,  and  in  every  part 
washable.  As  the  care  of  her  undergarments  is  of  even 
greater  importance  than  her  outer  clothing,  it  is  well  that 
her  laundry  should  be  done  with  the  family  work,  so  that 
the  famil}^  laundress  who  is  trusted  by  the  family  may  be 
charged  with  its  inspection. 

To  simplify  nursing  or  the  drawing  of  milk,  the 
author  has  devised  two  garments  for  wet-nurses.     The 


WET-NURSING.  55 

material  used  for  the  outer  garment  is  of  yellow  gingham, 
such  as  is  used  in  the  making  of  hospital  uniforms,  the 
yellow  color  being  selected  to  distinguish  the  wet-nurse 
from  the  blue,  as  used  by  the  nursing  corps.  The  cor- 
set-waist is  to  be  made  of  heavy  muslin.  The  corset,  if 
worn  at  all,  should  be  of  a  very  low  type,  so  as  to  avoid 
all  pressure  on  the  breasts.  It  is  best  of  a  cheap  quality, 
so  that  it  can  be  replaced  frequently  for  sanitary  reasons. 
Each  wet-nurse  should  be  supplied  with  four  uniforms 
and  six  nursing  corset-waists. 

The  Diet  of  the  Wet-nurse.  There  is  danger  of  the 
creation  of  indolent  habits  through  neglect  of  regular 
exercise  and  the  lack  of  regular  household  duties,  but 
even  greater  danger  lies  in  the  direction  of  overfeeding 
with  unusual  foods.  The  average  wet-nurse  is  either  ob- 
tained from  an  institution  or  a  home  in  which  the  lux- 
uries of  life  are  limited,  and  she  has  been  accustomed  to 
a  simple  nutritious  diet.  Every  attempt  should  be  made 
to  supply  the  nursing  woman  with  a  well-rounded  diet 
of  simple  foods,  with  milk  and  cereals  as  the  basis,  and 
these  supplemented  with  meats,  soups,  the  common  vege- 
tables, limited  amounts  of  fruits  and  plain  desserts.  In 
so  far  as  possible,  the  aromatic  vegetables,  unripe  and 
highly  acid  fruits,  fried  meats,  and  rich  pastries  are  to  be 
avoided.  We  believe  that,  on  the  whole,  too  great  stress 
has  been  laid  upon  the  danger  of  the  diet  in  the  mother 
of  a  full-term  infant,  and  in  most  cases  the  average 
mother  can  partake  of  a  very  full  diet.  However,  in  the 
case  of  the  woman  nursing  premature  infants,  it  should 
become  a  custom  to  allow  only  such  foods  during  the 
first  few  days  after  her  installation  as  can  be  given  with 
perfect  impunity.  When  a  full,  free  flow  of  milk  is 
established,  other  vegetables  and   fruits  can  be  added, 


56  INFANT   FEEDING. 

one  at  a  time,  and  after  each  addition  to  the  diet  a  try- 
out  should  be  given  the  milk.  We  have  on  numerous 
occasions  seen  marked  intestinal  distention  and  diarrheal 
attacks  following  even  seemingly  slight  indiscretions  of 
the  diet  on  the  part  of  the  wet-nurse.  It  is  our  hospital 
practice  to  furnish  each  wet-nurse  with  two  quarts  of 
good  wholesome  milk  daily,  and  at  least  one  pint  of 
cereal  gruel,  preferably  farina  or  corn-meal.  A  mixture 
of  milk  and  cereal  gruels  makes  a  very  good  combination 
for  drinking  midway  between  meals.  The  remainder  of 
the  milk  may  be  taken  with  the  meals,  either  pure  or  in 
the  form  of  cocoa,  tea,  or  weak  coffee,  in  whichever  form 
it  is  best  taken  by  the  individual  woman.  The  latter  is  of 
considerable  importance,  as  in  the  forced  diets  which  are 
required,  where  an  abundance  of  milk  is  demanded,  dis- 
tasteful foods  soon  become  obnoxious  in  large  quan- 
tities. 

Beers,  malt-extracts,  and  other  rich  drinks  are  not 
forced  upon  the  nurse,  unless  she  is  accustomed  to  them, 
and  feels  their  need.  It  must  always  be  remembered  that 
an  excess  of  fluids  would  naturally  tend  to  dilute  the 
milk  unless  the  secreting  gland  be  of  exceptional  develop- 
ment. 

Exercise  of  the  Wet-nurse  and  Her  Work.  She 
should  be  impressed  before  her  engagement  with  the  fact 
that  she  will  be  required  to  do  a  moderate  amount  of 
work  and  exercise  regularly  out  of  doors.  The  former 
will  be  of  service  in  promoting  her  general  health,  and 
both  the  work  and  the  exercise  will  serve  as  a  nerve  tonic 
and  prevent  her  becomnng  indolent.  This  does  not  mean 
that  she  should  become  a  drudge,  but  that  she  should  at 
least  be  required  to  care  for  her  own  room  and  her  own 
infant's  clothes,  and  should  be  made  to  feel  that  in  re- 


WET-NURSING;  57 

turn  for  her  laundry  work  she  would  be  requested  to  do 
some  light  general  work  about  the  house.  Her  exercise 
in  the  open  air  should  so  far  as  possible  be  at  regular 
times.  The  question  as  to  the  care  of  the  napkins  of  both 
babies  is  open  to  considerable  discussion ;  and  it  may  be 
stated  that  whenever  it  becomes  necessary  for  the  nurse 
to  express  her  milk  by  hand,  she  should  not  be  subjected 
to  the  handling  of  soiled  napkins,  whenever  this  can  be 
averted. 

Other   Conditions   Influencing  the   Quality 
of  the  Breast  Milk. 

The  nervous  and  mental  state  of  the  nurse  is  of  the 
utmost  importance,  and  wherever  possible  an  emotional, 
nervous,  erratic  v^oman  should  be  excluded,  because  of 
the  tendency  of  these  influences  to  suppress  the  flow  of 
milk.  Therefore,  whenever  possible,  a  woman  of  more 
or  less  phlegmatic  temperament  is  to  be  selected.  This 
is  especially  true  in  the  case  of  a  woman  who  is  to  be 
in  close  contact  with  and  is  to  nurse  an  infant  with  neu- 
rotic tendencies.  There  is  also  the  possibility  of  the  same 
influence  being  manifest  in  time  of  slight  indisposition 
on  the  part  of  her  own  infant,  and  such  an  individual  is 
also  more  likely  to  resent  the  necessity  of  partial  or  en- 
tire artificial  feeding  of  her  own  child  to  the  advantage  of 
the  premature  infant,  when  it  has  reached  such  an  age 
when  it  may  make  greater  demands  on  her  supply. 

Menstruation  rarely  produces  any  serious  disturb- 
ances. It  is  always  a  safe  procedure  to  dilute  the  milk 
during  the  first  and  the  second  day  of  menstruation  when 
the  nurse  suffers  considerable  pain  at  these  times. 

Period  of  lactation  may  or  may  not  be  a  considerable 
factor,  depending  upon  the  individual  woman.     At  the 


58  INFANT    FEEDING. 

present  writing  we  have  in  our  employ  a  nurse  who  has 
been  with  the  institution  for  sixteen  and  a  half  months, 
and  whose  infant  is  eighteen  months  old,  and  who  is  sup- 
plying us  with  the  largest  quantity  and  the  best  quality  of 
milk  of  the  four  nurses  in  the  institution.*  When  possible 
a  nurse  should  be  selected  after  the  first  few  weeks  of 
lactation,  at  which  time  the  colostrum  has  disappeared 
from  the  milk,  and  the  quantity  and  quality  of  her  milk 
has  become  established.  After  the  first  few  weeks  of  lac- 
tation, but  little  or  no  attention  is  to  be  paid  to  the  age 
of  the  wet-nurse's  baby  as  compared  with  that  of  the 
infant  to  be  fed,  and  we  have  never  noted  any  ill  effects 
following  this  rule. 

3.  The  Nursing. 

The  Infant's  Bedroom.  Under  ideal  circumstances, 
this  should  be  separated  from  that  of  the  wet-nurse. 
This  is  especially  true  where  a  trained  attendant  has  care 
of  the  infant.  It  should  under  all  circumstances  also  be 
separated  from  the  wet-nurse  when  she  is  of  a  low  de- 
gree of  intelligence  and  of  a  type  not  to  be  trusted  with 
the  care  of  the  infant. 


*  The  milk  of  this  nurse  was  examined  in  the  laboratories  of 
the  University  of  Chicago  after  seventeen  months  of  lactation 
with  the  following  result : 

Protein   1.98  per  cent. 

Casein 0.69 

Fat   3.54  "       " 

Lactose   7.025  "       " 

Salts    ; 0.1885  "       " 

It  must  be  remembered  that  this  is  an  exceptional  case,  and  but 
few  women  under  the  stress  of  ordinary  life  can  properly  nurse 
their  infants  after  the  ninth  to  twelfth  month. 


WET-NURSING. 


59 


Methods  of  Drawing  Milk.  Numerous  methods  of 
obtaining  milk  from  the  breasts  have  been  described,  but 
only  those  most  practicable  of  .  application  will  be  de- 
tailed. These  should  be  divided,  first,  into  those  in  which 
the  baby  is  placed  directly  at  the  breast,  and  those  meth- 


Fig.  1. — Proper  method  of  holding  baby  during  nursing. 

ods  by  which  the  milk  is  drawn  from  the  breasts  and  fed 
to  the  infant.  Two  methods  are  especially  applicable 
where  the  baby  is  fed  directly  on  the  breast,  and  needs 
assistance  because  of  its  weakness. 

1.  Premature  infant  is  placed  at  the  breast,  and  is 
supported  there  by  the  nurse's  right  arm  while  nursing  at 
the  right  breast,  and  the  left  hand  is  used  to  grasp  the 
breast  just  above  the  nipple  between  two  fingers   (see 


60 


INFANT    FEEDING. 


p.  59),  and  the  milk  is  expressed  directly  into  the  baby's 
mouth.  In  this  way  the  baby  is  taught  to  take  the  breast, 
and  at  the  same  time  receives  its  food  with  little  effort. 
This  method  can  be  continued  until  the  baby  has  gained 
sufficient  strength  to  nurse  without  assistance. 

2.  Much  of  the  same  result  can  be  accomplished  by 
placing  the  wet-nurse's  baby  on  the  opposite  breast  dur- 
ing the  nursing  period,  whereupon  the  simultaneous  nurs- 


Fig.  2. — Author's  improved  breast  milk  collector.  The 
pump  is  made  in  two  types,  the  first  filled  with  a  large  rub- 
ber bulb  of  a  size  considerably  larger  than  is  ordinarily 
sold  with  a  breast-pump,  and  the  second  with  an  attach- 
ment to  which  the  Holz  vacuum  pump  can  be  fitted.  In 
place  of  the  ordinary  collecting  bulb  at  the  lower  surface, 
an  arm  is  so  constructed  as  to  allow  the  milk  to  drain  into 
specially  designed  graduated  2-ounce  milk  flasks. 

ing  on  both  breasts  will  cause  a  free  flow  of  milk  into 
both  sides. 

In  those  methods  by  which  the  milk  is  drawn  from  the 
breasts  and  fed  to  the  infant  by  hand  or  by  other  means. 

1.  By  the  breast-pump.  The  modification  of  Holz 
vacuum  apparatus,  as  devised  by  the  author,  by  which 


WET-NURSING. 


61 


means  the  milk  is  drawn  directly  into  two  graduated  2- 
ounce  flasks,  which  can  be  filled  to  the  quantity  desired, 
and  stoppered  for  future  use,  so  that  the  milk  is  free 
from  handling,  and  thereby  avoid  contamination. 


Fig.  3. — Direct  expression  of  milk  (act  1).  Glass  grad- 
uate is  held  against  breast  one  inch  to  one  inch  and  a-half 
back  of  the  nipple,  and  held  in  position  by  the  bent  fore- 
finger of  the  left  hand.  Thq  left  thumb  gently  grasps  the 
upper  part  of  the  breast  about  one  inch  behind  the  nipple. 
The  thumb  of  the  left  hand  gently  compresses  the  breast 
against  the  side  of  the  glass  with  a  gentle  sweeping  move- 
ment.   This  is  repeated  40  to  60  times  per  minute. 

2.  By  direct  expression,  which  is  performed  as   fol- 
lows :   A  graduated  glass  is  held  against  the  underside  of 


62 


INFANT   FEEDING. 


the  lower  inch  of  the  breast  and  nipple  by  the  index  and 
middle  finger  and  a  downward  sweeping  stroke  is  used  to 
compress  the  corresponding  part  of  the  breast  and  the 
nipple  against  the  side  of  the  glass  receptacle.  The  ves- 
sel can  be  supported  with  the  other  hand.    By  this  means, 


Fig.  4. — Direct  expression  of  milk    (act  2), 


following  a  little  practice,  the  nurse  can  express  from  6 
to  8  ounces  of  milk  from  two  good  breasts  in  fifteen  to 
twenty  minutes.  While  drawing,  each  2  ounces  of  milk 
is  poured  directly  into  sterile,  stoppered  bottles,  to  prevent 
the  fingers  of  the  nurse  coming  in  contact  with  the  milk 
by  overfilling  the  glass.  It  goes  without  saying  that  be- 
fore  each   expression   the   breasts   must   be   thoroughly 


•      WET-NURSING.  63 

cleansed  with  a  boric  acid  solution,  and  the  hands  thor- 
oughly washed  with  soap  and  water. 

Daily  Number  of  Expressions.  Expression  is  per- 
formed six  times  daily  at  regular  intervals  of  four  hours 
during  the  day  and  night. 


CHAPTER    IV. 
THE    NURSING   INFANT. 

Signs  of  Successful  Nursing.  The  normal  full-term 
infant  shows  a  gain  of  not  less  than  4  ounces  weekly. 
This  is  the  minimum  weekly  gain  which  may  safely  be 
allowed.  When  a  nursing  baby  remains  stationary  in 
weight  or  makes  a  gain  of  but  2  or  3  ounces  a  week,  it 
means  that  something  is  wrong,  and  the  defect  will  usu- 
ally, but  not  invariably,  be  found  in  the  milk  supply. 
When  the  baby  is  nursed  at  proper  intervals,  and  the 
supply  of  milk  is  ample  and  of  good  quality,  it  is  satis- 
fied at  the  completion  of  the  nursing.  Under  three 
months  of  age  it  falls  asleep  after  ten  or  twenty  minutes 
at  the  breast.  When  nursing  period  again  approaches,  it 
becomes  restless  and  unhappy,  crying  lustily  if  the  nurs- 
ing be  delayed.  When  the  breast  is  offered,  it  takes  it 
greedily.  The  weekly  gain  in  weight  under  such  condi- 
tions is  usually  from  4  to  8  ounces.  At  the  fifth  month 
the  baby  will  have  doubled,  and  at  the  twelfth  month 
trebled  its  birth  weight.  The  average  gain  per  week  dur- 
ing the  first  year  is  about  4  ounces. 

The  baby  increases  in  length  from  about  20.5  inches 
(50  cm.)  to  28.5  inches  (70  cm.)  in  the  first  year.  The 
first  tooth  appears  at  about  the  sixth  or  seventh  month, 
and  at  one  year  there  should  be  six  teeth  or  more.  (Age 
in  months  minus  6  =  number  of  teeth  normally  present 
at  that  age.)  It  begins  to  smile  at  about  the  fifth  week, 
grasps  objects  and  holds  its  head  erect  in  the  fourth 
month,  sits  alone  for  a  few  minutes  at  seven  or  eight 
months,  bears  its  w^eight  on  its  feet  at  the  ninth  or  tenth 
(64) 


THE   NURSING   INFANT.  65 

month,  stands  with  slight  assistance  at  the  eleventh  or 
twelfth  month,  and  creeps  or  walks  soon  after  this  (tenth 
to  eighteenth  month,  average  fourteenth  month),  and 
says  a  few  words  towards  the  end  of  the  first  year. 

Stools..  The  feces  of  breast-fed  babies  are  strikingly 
uniform,  and  are  like  no  other  bowel  movement  in  in- 
fancy. Normally,  there  are  two  or  three  a  day,  some 
times  only  one,  or  even  more  than  three.  They  are  soft, 
or  mushy,  homogeneous,  of  an  egg-yellow  or  gold  color, 
and  have  a  slightly  sour,  not  at  all  unpleasant  odor.  They 
are  never  formed,  and  always  cling  to  the  diaper.  The 
nature  of  the  bowel  movement,  and  its  uniformity,  is  due 
to  the  "physiological  fecal  flora"  which  is  brought  about 
by  the  ingestion  of  breast  milk  into  the  germ-laden  in- 
testinal tract,  and  which  in  turn  have  a  fermentative 
rather  than  a  putrefactive  action  on  the  food.  The  gases 
normally  formed  are  carbon  dioxide  and  hydrogen,  and 
these  are  practically  odorless.  The  acidity  of  the  move- 
ment, its  softness,  and  the  mechanical  action  of  the  gases 
present,  all  insure  active  peristalsis  and  ready  emptying 
of  the  bowels,  so  that  constipation  is  an  exceptional  con- 
dition in  a  breast-fed  baby,  and,  if  present,  it  nearly  al- 
ways suggests  too  little  food,  or  abdominal  and  intestinal 
muscles  too  little  developed  and  too  weak  to  force  the 
stool  past  the  anal  sphincter.  This  latter  condition  is 
commonly  interpreted  as  constipation  by  the  laity. 

The  dried  residue  of  the  feces  contains  from  10  to  30 
per  cent,  of  fat,  about  8  per  cent,  salts,  a  very  large  per- 
centage of  bacteria,  bile  pigments,  intestinal  secretion 
(mucus,  etc.),  epithelial  cells,  etc.  No  food  proteins  or 
carbohydrates  are  found. 

The  feces  of  the  breast-fed  baby  are  very  frequently 
not  wholly  normal;  they  quite  commonly,  especially  dur- 


66  INFANT   FEEDING. 

ing  the  first  'few  months,  contain  small,  soft,  white  or 
yellowish  fat  curds,  an  excess  of  mucus,  and  are  often 
greenish  in  color,  and  may  be  more  frequent  than  nor- 
mal. Swch  a  condition  is  perfectly  consistent  with  a  nor- 
mal growth  and  zuell-being  of  the  baby,  and  should  never 
in  itself  be  a  cause  of  worry,  or  an  indication  for  a 
change  of  food.  This  is  a  very  important  point  that  is 
very  commonly  neglected.  The  condition  of  the  bowel 
movements  is  only  one  factor,  and  in  the  breast  fed  a 
minor  one,  in  determining  a  baby's  nutrition. 


CHAPTER    V. 

MIXED    FEEDING    AND    WEANING. 

Mixed  Feeding  (allaitement  mixte).  With  a  dimi- 
nution in  the  amount  of  milk  secreted,  the  breast  milk 
must,  of  course,  be  complemented  or  supplemented  by 
modified  cow's  milk.  These  methods  of  feeding  are  usu- 
ally successful.  By  complemental  feeding  we  mean  the 
administration  of  milk  from  a  bottle  following  a  period  at 
the  breast  at  each  nursing.  By  supplemental  feeding  sub- 
stitution of  a  bottle  for  a  breast  feeding  is  meant.  Thus, 
in  the  former  the  baby  receives  as  many  part  bottle  as 
breast  feedings,  while  in  the  latter  it  will  be  supplied  with 
one  or  more  bottle  feedings  to  replace  breast  feedings. 
As  we  know  that  the  breast  secretes  in  proportion  to  its 
stimulation,  the  complementary  feeding  is  far  more  satis- 
factory, and  not  infrequently  it  is  wise  to  nurse  both 
breasts  for  a  short  time,  let  us  say,  each  one  three  to 
five  minutes,  before  the  bottle  is  given.  The  modified 
milk  strength  should  be  that  which  is  suitable  for  the 
average  child  of  the  same  age  (see  Artificial  Feeding). 
In  beginning  the  use  of  cow's  milk,  however,  it  must  be 
remembered  that  at  first  a  weaker  strength  must  be  used 
than  the  child  will  require  for  growth,  this  weaker  food 
being  necessary  in  order  gradually  to  accustom  the  infant 
to  the  change.  If  too  strong  a  cow's  milk  mixture  is 
given  at  first,  it  will  be  very  apt  to  disagree,  causing  colic 
and  vomiting.  Later,  when  the  child  has  become  accus- 
tomed to  the  new  food,  a  stronger  mixture  may  be  given. 
When  a  mother  cannot  give  her  infant  at  least  two  satis- 
factory breast  feedings  daily,  it  is  advisable  to  wean  the 

(67) 


68  INFANT   FEEDING. 

child.  The  newborn  baby  is  not  very  discriminating,  and 
will  nurse  anything  equally  well.  The  older  baby,  how- 
ever, quickly  prefers  the  easy-flowing  bottle  to  the  in- 
creasingly unsatisfactory  breast,  and  will  quite  regularly 
stop  nursing  at  the  breast  as  the  milk  comes  harder  and 
is  less  abundant.  If  the  bottle  is  given  right  after  the 
breast,  it  is  always  well  to  use  a  nipple  from  which  the 
milk  comes  with  some  difficulty,  for  the  reasons  given 
above.  If  it  is  desirable  to  wean  the  baby  rather  quickly, 
this  method  of  following  the  breast  by  the  bottle  is  often 
to  be  preferred  to  the  other. 

Indications  for  Weaning.  Pregnancy  is  usually  an 
indication  for  weaning.  The  mother's  milk  becomes 
more  scanty,  and  often  poor  in  quality.  This  is  especially 
the  case  if  the  mother  knows  she  is  pregnant,  and  has 
been  taught  that  a  pregnant  woman  should  never  nurse  a 
baby.  If  the  baby  continues  to  thrive  at  the  breast,  there 
is  no  reason  why  nursing  should  not  be  prolonged.  For- 
tunately a  new  pregnancy  does  not  often  supervene  be- 
fore a  time  that  makes  it  quite  safe  to  wean  the  nursing 
baby,  i.e.,  before  the  sixth  month. 

In  acute  infections  in  the  mother,  such  as  pneumonia, 
and  the  acute  contagious  diseases,  such  as  scarlet  fever, 
one  must  weigh  the  danger  from  exposure  to  infection  as 
against  the  quality  of  the  artificial  food  and  environ- 
ment in  the  individual  case. 

In  the  milder  contagious  diseases,  such  as  measles, 
mumps,  it  is  true  that  young  breast-fed  infants  are  rarely 
infected.  Pertussis  is  an  exception,  and  has  a  high  mor- 
tality in  the  newborn  and  young  infants;  and  the  infant 
should  under  all  circumstances  be  protected  from  ex- 
posure. In  the  presence  of  diphtheria  the  infant  can  be 
immunized  with  safety. 


\ 


MIXED    FEEDING   AND   WEANING.  69 

Weaning  should  always  be  done  gradually,  when  pos- 
sible, for  the  sake  of  both  mother  and  the  child.  In 
cases  of  sudden  weaning,  the  food  must  be  very  much 
weaker  in  the  beginning  than  for  an  artificially  fed  child 
of  the  same  age.  If  weaned  at  six  months,  the  infant 
should  be  put  on  a  mixture  suitable  for  a  child  of  two  or 
three  months,  and  the  same  rule  applies  for  older  infants. 
When  the  infant  becomes  accustomed  to  cow's  milk,  the 
strength  can  gradually  be  increased.  Rarely  should 
breast  feeding  be  continued  beyond  the  first  year. 

The  fear  of  the  laity  of  the  ''second  summer"  is  well 
founded  when  dirty  milk  and  other  improper  foods  are 
fed  promiscuously,  but  with  clean,  certified,  and  sterilized 
milk,  and  properly  prepared  soft  foods,  the  dangers  of 
the  summer  heat  are  minimized.  It  should  be  our  rule 
to  underfeed  rather  than  overfeed  in  hot  weather,  and 
during  the  hot  spells  the  infant's  diet  may  well  be  re- 
duced one-half. 

Care  of  the  Breasts  During  Weaning.  When  the 
breast  feeding  is  carried  on  the  usual  length  of  time 
(from  nine  to  twelve  months),  the  process  of  weaning 
ordinarily  causes  little  or  no  discomfort.  All  that  is  usu- 
ally required  is  to  press  out  enough  of  the  milk  to  re- 
lieve the  patient  as  often  as  the  breast  becomes  painful, 
which  may  not  be  more  than  two  or  three  times  a  day. 
When  the  weaning  is  necessarily  abrupt,  no  little  dis- 
comfort may  result.  When  the  weaning  can  be  accom- 
plished more  gradually,  the  infant  should  have  one  less 
nursing  every  second  or  third  day,  until  only  two  are 
given  daily.  After  this  has  been  practised  for  one  week, 
nursing  should  be  discontinued.  In  cases  of  sudden 
weaning,  a  saline  laxative,  such  as  citrate  of  magnesia  or 
Rochelle  salts^  should  be  given  every  day  for  five  days — 


70  INFANT   FEEDING. 

sufficient  to  produce  two  or  three  watery  evacuations 
daily.  In  the  meantime  the  mother  should  abstain  from 
fluids  of  all  kinds  up  to  the  point  of  positive  discomfort. 
The  breasts  should  be  elevated  by  a  firm  binder. 


CHAPTER    VI. 

NUTRITIONAL    DISTURBANCES    IN    THE 
BREAST-FED  INFANT. 

Breast  milk  alone  furnishes  all  of  the  needs  for 
growth  and  development  of  the  human  offspring.  The 
infant  will  thrive  in  most  instances  on  breast  milk  from 
different  sources  and  different  quality,  demonstrating  the 
ability  of  the  average  infant  to  assimilate  the  food  which 
Nature  intended  for  its  use,  even  though  the  percentage 
quantity  of  the  various  components  may  vary  greatly. 
Disturbances  in  the  breast-fed  baby  are  dependent  upon 
one  or  more  of  several  factors.  In  the  order  of  their  fre- 
quency they  may  be  divided,  as  follows. 

1.  Underfeeding. 

2.  Overfeeding. 

3.  Congenital  debility,  with  resulting  impairment  of 
the  vital  functions. 

4.  Intercurrent  parenteral  (pharyngitis,  tonsillitis, 
bronchitis,  pneumonia,  pyelitis,  etc.)  and  enteral  in- 
fections. 

5.  Idiosyncrasy  towards  mother's  milk. 

While  all  nutritional  disturbances  in  young  infants  are 
of  serious  import,  they  are  far  less  dangerous  than  those 
of  the  artificially  fed  infant,  and  much  more  easily  cor- 
rected. They  are  also  much  less  frequent  than  nutritional 
disturbances  in  artificially  fed  infants. 

1.  Underfeeding. 

Etiology.  Two  factors  of  prime  importance  must 
be  investigated  to  complete  the  diagnosis : 

(71) 


72  INFANT   FEEDING. 

(1)  The  daily  quantity  of  the  milk  furnished  to  the 

infant. 

(2)  The  quality  of  the  milk  supplied  by  the  mother. 
The  milk  may  contain  the  normal  percentage  of  fat, 

sugar,  and  protein,  but  be  scanty  in  amount.  Instead  of 
the  4  or  5  ounces  to  which  the  child  is  entitled,  it  may 
get  but  1  or  2  ounces.  Whether  or  not  the  quantity  is 
sufficient,  may  be  determined  by  weighing  the  baby  be- 
fore and  after  each  nursing  for  twenty-four  hours. 
(The  ordinary  spring  balance  infant  scale  will  not 
answer,  and  a  simple  beam  scale  with  weights  and  scoop 
should  be  supplied.)  One  ounce  of  breast  milk  weighs 
practically  1  ounce  avoirdupois.  By  nursing  for  fifteen 
minutes,  a  child  under  one  week  old  should  gain  1  to  1.5 
ounces;  at  three  weeks  of  age,  1.5  to  2  ounces;  four  to 
eight  weeks  of  age,  2  to  3  ounces;  eight  to  sixteen  weeks 
of  age,  3  to  4  ounces ;  sixteen  to  twenty-four  weeks  of 
age,  5  to  7  ounces;  six  to  nine  months  of  age,  6  to  8 
ounces ;  nine  to  twelve  months  of  age,  8  to  9  ounces.  Of 
course,  arbitrary  limits  cannot  be  fixed  as  to  the  quan- 
tity. It  is  not  necessary  to  worry  about  the  quantity 
taken  at  individual  feedings  so  long  as  the  infant  is  mak- 
ing satisfactory  gains  in  weight,  and  the  general  progress 
is  good. 

Quantity  of  Human  Milk  Required  by  the  Nursing 
Baby.  Babies  of  the  same  age  and  weight,  under  the  same 
conditions,  will  take  nearly  the  same  amount  of  food.  The 
older  and  larger  the  baby,  the  larger  the  total  quantity  of 
food  required,  but  its  energy  quotient — that  is,  the  num- 
ber of  calories  per  kilogram  or  a  pound  of  weight — lessens 
steadily  with  increasing  age.  The  daily  amount  that  nor- 
mal, thriving  babies  take  from  the  breast  can  be  stated 
at  about  one-sixth  to  one-fifth  of  their  body  weight  dur- 


NUTRITIONAL   DISTURBANCES.  73 

ing  the  first  month,  about  one-sixth  to  one-seventh  up  to 
the  sixth  month,  and  about  one-eighth  after  the  sixth 
month.  Heubner  expressed  this  in  terms  of  energy 
quotient,  as  follows :  "During  the  first  few  months  an 
infant  requires  100  calories  per  kilogram  daily  of  breast 
milk ;  after  the  sixth  month  this  energy  quotient  gradually 
comes  down  to  80  or  85  at  the  end  of  the  first  year.  An 
energy  quotient  of  70  is  about  the  minimum  amount  that 
an  infant  can  take  without  losing  weight."  Human  milk 
can  be  estimated  at  21  calories  per  ounce,  and  about  70 
calories  per  100  Gm.  of  milk.  With  these  figures  in 
mind,  it  is  easy  to  determine  whether  a  breast-fed  infant 
gets  about  the  right  amount  of  food,  and  we  have  also  a 
valuable  standard  by  which  to  measure  the  food  of  an 
artificially  fed  infant. 

Symptoms.  Failure  to  gain  weight  properly,,  or  even 
a  loss  in  weight,  may  be  the  first  positive  evidence  of  an 
insufificient  food  supply.  Usually  this  is  associated  with 
more  or  less  evidence  of  dissatisfaction  on  the  part  of  the 
infant.  The  infant's  sleep  becomes  disturbed,  and  it 
becomes  restless,  and  cries  long  before  the  next  feeding 
time.  Again,  it  may  manifest  its  dissatisfaction  by  nurs- 
ing greedily  for  a  short  time,  releasing  the  breast  and 
crying.  It  returns  to  the  breast  again,  but  with  the  same 
result ;  or  in  other  instances  the  infant  will  remain  at  the 
breast  for  much  longer  periods  than  should  be  necessary 
to  obtain  the  food  that  it  needs,  which  would  be  accom- 
plished in  from  ten  to  twenty  minutes. 

Usually  the  stools  are  normal  in  appearance,  but  small 
in  amount,  and  give  little  evidence  of  the  cause  of  the 
trouble.  However,  if  the  food  supply  be  decidedly  in- 
sufficient, we  may  have  a  positive  evidence  of  the  under- 
feeding  by    the    appearance    of    the    so-called    "hunger 


74  INFANT   FEEDING. 

stools,"  which  are  of  more  or  less  brownish  or  greenish- 
brown  color,  containing  little  fecal  matter  and  much 
mucus. 

If  the  condition  is  not  corrected,  the  baby  becomes 
weak  and  apathetic.  The  skin  loses  its  turgor,  its  tem- 
perature becomes  subnormal,  it  is  pale  and  anemic,  the 
fontanelles  become  depressed,  and  the  abdomen  sunken. 
Whenever  there  is  room  for  doubt  as  to  the  cause  of  this 
group  of  symptoms,  the  scale  will  be  the  most  positive 
evidence. 

Treatment.  Undue  haste  in  removing  the  baby  from 
the  breast  offers  the  greatest  danger  in  the  treatment  of 
underfeeding,  and  should  be  resorted  to  only  when  other 
means  fail.  The  ability  to  increase  the  quantity  of  milk 
secreted  by  the  average  woman  must  necessarily  vary 
directly  with  the  quantity  and  quality  of  the  glandular  tis- 
sue composing  the  breast.  However,  to  a  certain  extent 
at  least,  certain  factors  will  more  or  less  'directly  in- 
fluence the  quantity  and  quality  of  the  secretion,  and  they 
are  worthy  of  our  attention. 

Means  of  Stimulating  the  Breasts.  The  surroundings 
of  the  mother  must  predispose  to  a  happy  frame  of  mind ; 
she  must  not  be  overburdened  with  household  cares ;  her 
exercise  must  be  regular,  and  she  must  be  relieved  of 
worry  and  lack  of  sleep.  It  is  well,  if  possible,  to  free 
her  from  all  care  of  the  baby,  especially  at  night.  She 
should  be  put  in  as  good  physical  condition  as  possible; 
she  should  get  out;  of  doors. 

Her  appetite  should  be  stimulated,  so  that  she  will  take 
an  abundance  of  milk  and  other  nutritious  food.  The 
very  common  forced  feeding  beyond  the  natural  appe- 
tite, is  of  questionable  value.  The  general  rules  as  to  the 
diet    previously    spoken    of    should    be   maintained.      It 


NUTRITIONAL   DISTURBANCES.  75 

should,  however,  be  remembered  that  an  excessive  diet 
may  be  assimilated  by  the  mother's  body  without  increas- 
ing the  flow  of  milk.  The  fluids  given  should  be  palat- 
able to  the  nursing  mother,  and,  as  previously  recom- 
mended, milk,  weak  tea,  cocoa,  farina,  oatmeal,  and  corn- 
meal  gruels  as  well  as  milk  soups  are  probably  the  best. 
The  fat  and  the  protein  of  the  milk  can  more  especially 
be  influenced  by  the  diet.  The  fats  are  increased  by  over- 
feeding with  fats  and  carbohydrates,  with  little  or  no 
exercise.  They  are  reduced  by  limiting  these  articles  and 
substituting  vegetables,  and  by  increasing  the  amount  of 
exercise.  The  protein  is  also  increased  by  overfeeding 
and  limited  exercise.  The  carbohydrates  are  less  in- 
fluenced by  the  diet,  but  are  also  affected  by  an  excess 
of  carbohydrate  feeding.  Alcohol  in  the  form  of  malted 
drinks  has  a  temporary  influence  in  increasing  the  quan- 
tity of  milk  and  the  amount  of  fat.  The  effect  on  the 
protein  is  less  constant.  We  never  force  a  woman  to 
partake  of  alcoholic  liquors  unless  she  desires  them,  be- 
cause of  the  moral  as  well  as  of  the  physical  effect. 

Stimulating  massage  may  be  applied  to  the  breast  in 
such  a  manner  as  to  stimulate  the  whole  gland.  This 
can  best  be  accompHshed  by  two  movements:  (1)  by 
gently  raising  the  whole  breast  from  the  chest  wall  and 
kneading  it  gently  between  the  fingers,  and  (2)  by  hold- 
ing the  breast  against  one  hand  and  making  circular 
movements  around  the  periphery  with  the  outspread 
finger  tips  of  the  other  hand,  and  gradually  working  from 
its  base  towards  the  nipple. 

Baths  at  a  temperature  comfortably  cool  (80°  to  90° 
F.)  should  be  taken  daily  to  promote  her  general  health 
as  well  as  cleanliness.  These  should  be  followed  by  a 
brisk  rubbing  with  a  coarse  towel.    • 


76  INFANT   FEEDING. 

Steaming  the  breasts  by  the  application  of  hot  towels 
covered  with  oiled  silk  two  or  three  times  daily  is  of 
decided  benefit. 

The  Bier  pump  and  other  means  of  stimulating  an  arti- 
ficial hyperemia  can  be  used  to  advantage  in  obstinate 
cases.  The  application  should  be  made  at  regular  inter- 
vals, and  not  too  long  continued.  A  very  simple  vacuum 
pump  may  be  made  by  boring  a  round  hole  into  a  finger- 
bowl  and  inserting  a  piece  of  rubber  tubing  and  attaching 
a  clamp,  which  can  be  opened  and  closed  at  will. 

Galactagogues  of  any  material  value  for  permanent 
use  are  unknown.  Pituitrin  has  been  recommended  for 
temporary  stimulation.  We  have  not  had  much  experi- 
ence in  its  use.  General  tonic  will  often  improve  the 
digestion  and  tend  to  overcome  the  anemia,  and  in  this 
way  improve  the  general  health,  and  thereby  lactation. 

2.  Overfeeding. 

This  condition  is  a  rare  one  in  the  breast-fed  baby, 
and,  when  present,  in  all  but  the  very  young  and  pre- 
mature, nature  often  provides  its  own  remedy,  either  by 
regurgitation  on  the  part  of  the  baby,  or  by  its  refusal  to 
nurse  longer  than  to  meet  its  needs,  which  latter  soon 
leads  to  a  lessened  milk  secretion.  In  the  first  weeks  and 
months  it  may  be  of  considerable  importance,  and  may 
cause  grave  symptoms  on  the  part  of  the  infant — that  is, 
before  the  mother's  breast  and  the  infant  have  become 
adapted  to  one  another. 

Etiology.  Although  overfeeding  in  the  breast-fed 
infant  is  rare  when  compared  with  overfeeding  on  arti- 
ficial food,  yet  next  to  underfeeding  it  is  the  most  com- 
mon form  of  nutritional  disturbance  in  the  breast-f^d 


NUTRITIONAL   DISTURBANCES.  77 

infant.  It  is  also  more  commonly  present  in  infants  fed 
by  a  wet-nurse  than  in  infants  nursing  the  maternal 
breast. 

Usually  the  error  lies  in  too  frequent  nursing. 

Rarely  it  may  be  due  to  excessive  quantities  of  milk 
taken  at  proper  intervals. 

Occasionally  it  is  due  to  milk  which  is  excessively  rich 
in  fat. 

Pathogenesis.  The  normal  infant's  stomach  on 
breast  feeding  empties  itself  in  about  two  hours.  When 
all  the  food  has  left  the  stomach,  and  is  undergoing  intes- 
tinal digestion,  free  hydrochloric  acid  is  forming  in  the 
stomach.  Free  hydrochloric  acid  is  antiseptic,  and  it  also 
stimulates  secretion  of  pancreatic  juice  and  secretion  of 
bile,  both  of  the  latter  products  being  essential  to  proper 
intestinal  digestion. 

For  normal  digestion  it  is  therefore  necessary  that  the 
stomach  remain  empty  for  some  time  after  all  the  food 
has  left  it.  When  by  too  frequent  nursings  no  time  is 
allowed  for  the  above  described  physiological  process,  or 
when  by  excessive  quantities  of  food  at  proper  intervals 
too  great  demands  are  made  upon  the  hydrochloric  acid, 
and  the  time  of  gastric  digestion  lengthened,  with  cor- 
responding shortening  of  the  period  of  comparative  rest, 
or  the  gastric  secretion  diminished  by  excessive  fat,  then 
we  may  expect  disturbance  of  the  normal  digestion  due 
to  overfeeding. 

Symptoms.  The  earliest  symptoms  are  regurgita- 
tion, diarrhea,  and  lessened  appetite.  These  three  symp- 
toms are  reactions  of  the  organism  to  excessive  intake  of 
food  attempting  to  get  rid  of  the  excess. 

Regurgitation  occurs  at  first  occasionally  only,  imme- 
diately after  nursing,  and  without  any  discomfort  on  the 


7S  INFANT   FEEDING. 

part  of  the  infant  ("spitting").  The  regurgitated  fluid 
is  often  unchanged  milk.  This  is  usually  the  first  pre- 
monitory symptom. 

Diarrhea  follows  when  overfeeding  continues  and  re- 
gurgitation becomes  insufficient  to  rid  the  body  of  excess 
of  food.  The  stools  are  more  frequent  than  normal,  and 
contain  undigested  particles  of  food. 

Lessened  appetite,  although  present  in  many  cases, 
may  be  replaced  by  symptoms  suggestive  of  hunger,  the 
infant  taking  the  breast  and  nursing  greedily.  This  ap- 
parent symptom  of  underfeeding  and  of  hunger  may 
wrongly  be  interpreted,  and  lead  to  additional  overfeed- 
ing by  giving  the  breast  at  even  more  frequent  intervals 
to  allay  the  apparent  hunger  and  to  quiet  the  restless 
infant. 

In  many  cases  no  other  symptoms  develop,  the  condi- 
tion undergoing  a  spontaneous  cure.  The  breasts  lessen 
their  yield,  and  thus  the  cause  of  the  condition  disap- 
pears, or,  on  the  other  hand,  the  digestive  power  of  the 
infant  increases  to  such  an  extent  as  to  be  able  to  take 
care  of  the  excess,  if  not  too  large.  This  accounts  for  the 
fact  that  frequently  the  above-named  symptoms  are 
neglected,  since  they  usually  produce  improvement  in 
the  child's  condition,  and  are  regarded  as  passing  dis- 
turbances without  much  importance.  When,  however, 
they  are  entirely  neglected,  and  excess  of  the  food  con- 
tinued, or  even  increased,  due  to  wrong  interpretation  of 
symptoms,  then  more  serious  symptoms  develop,  and  the. 
condition  reaches  a  stage  where  spontaneous  cure  rarely 
occurs. 

Vomiting  becomes  habitual,  occurring  from  a  few 
minutes  to  half  an  hour  after  nursing.  It  is  accom- 
panied by  visible  discomfort  and  straining  on  the  part  of 


NUTRITIONAL   DISTURBANCES.  79 

the  infant.  The  vomitus  consists  of  curdled  milk,  mucus, 
and  gastric  juice.  Between  vomiting  there  is  often  pain- 
ful belching.  Stomach  shows  distention,  and  empties 
itself  only  after  three  to  four  hours.  Free  hydrochloric 
acid  is  almost  or  entirely  absent,  the  acid  products  of  fer- 
mentation being  present.  The  micro-organisms  are  in- 
creased in  number  and  variety,  due  to  stagnation  and  ab- 
sence of  antiseptic  free  hydrochloric  acid. 

Initial  diarrhea  is  sometimes  followed  by  temporary 
constipation,  diarrhea  setting  in  again.  The  evacuation 
is  painful,  and,  with  much  gurgling  and  discharge  of 
gases,  fluid  masses  are  squirted  from  the  anus.  The 
stools  are  watery,  with  white  and  dark  green  fragments, 
and  of  disagreeable,  sour,  pungent  odor.  The  irritating 
feces  often  causes  eczema  and  intertrigo  in  the  ano- 
genital  region. 

Abdomen  is  distended,  tense,  and  often  there  is  visible 
peristalsis.  Intestinal  colic  causes  restlessness  and  cry- 
ing; the  infant's  face  gives  expression  to  its  pain,  and,  as 
the  fermentation  increases,  its  agony  is  increased,  due 
to  intestinal  paresis. 

The  infant  becomes  restless ;  its  sleep  is  much  dis- 
turbed, and  even  during  sleep  its  features  give  evidence 
of  its  distress. 

The  weight  early  becomes  stationary,  and  in  severer 
cases  associated  with  dyspepsia  loss  of  weight  becomes 
marked. 

Complications.  Dyspepsia.  Accompanied  by  the 
milder  evidence  of  intestinal  irritation,  evidenced  by  in- 
creased peristalsis,  with  its  resultant  colic,  more  or  less 
numerous  bowel  movements  of  eight  or  ten  or  even  more 
daily,  sour  and  irritating,  greenish-yellow  in  color,  and 


80  ,  INFANT   FEEDING. 

containing  numerous  curds  and  much  mucus.  The.  but- 
tocks soon  become  reddened  and  intertrigo  results. 

Intoxication,  while  rare  in  the  breast-fed  infant,  may 
result  when  the  dyspepsia  is  neglected.  The  baby  be- 
comes drowsy  and  stuporous,  paying  little  attention  to 
its  surroundings,  and  not  infrequently  develops  a  severe 
anorexia,  all  associated  with  more  profound  intestinal 
symptoms. 

In  dyspepsia  the  intestinal  findings  dominate  the  pic- 
ture, while  in  intoxication  they  share  their  prominence 
with  the  added  nervous  symptoms. 

Pyelitis  is  not  an  infrequent  complication  in  neglected 
dyspepsia  and  intoxication,  and  while  it  undoubtedly  is 
frequently  due  to  an  ascending  infection,  it  may  re- 
sult from  extension  through  the  blood  stream  or  the 
lymphatics. 

Eczema  not  infrequently  results  from  overfeeding  in 
the  breast-fed  infant,  and  is  usually  seen  in  the  fat  type 
of  infant  who  is  otherwise  healthy. 

Pylorospasm,  gastric  dilatation  are  not  uncommon  in 
the  neglected  cases. 

Acidosis  may  develop  in  the  extreme  cases,  associated 
with  great  loss  of  weight,  but  this  is  rare. 

Diagnosis.  In  the  presence  of  symptoms  suggestive 
of  overfeeding,  positive  diagnosis  is  made  by  determin- 
ing exactly  the  amount  of  milk  taken  by  the  infant,  and 
comparing  this  amount  with  what  an  infant  of  the  same 
weight  and  of  the  same  age  should  get.  The  method  of 
this  determination  has  been  described  in  detail  under  the 
treatment  of  underfeeding. 

If,  however,  the  food  is  found  to  be  quantitatively  cor- 
rect, occasionally  information  of  value  may  be  obtained 
by  examining  the  quality  of  the  milk  chemically,  espe- 


NUTRITIONAL   DISTURBANCES.  81 

cially  as  to  its  fat  content.  The  specimen  for  examina- 
tion should  be  taken  under  precautions  pointed  out  under 
Examination  of  Human  Milk.  By  making  proper  etio- 
logical diagnosis,  valuable  indications  for  rational  treat- 
ment are  obtained. 

If  a  careful  search  is  made  for  the  etiological  factors 
lin  the  common  illnesses  of  infants,  which  are  so  fre- 
quently charged  to  overfeeding,  one  will  be  surprised  to 
find  that  the  error  lies  in  the  diagnosis,  and  that  in  most 
cases  the  condition  is  not  due  to  overfeeding.  This  leads 
us  to  warn  against  the  only  too  frequent  habit  of  wean- 
ing infants  without  a  careful  study  of  the  exact  cause 
of  the  infant's  trouble. 

Treatment.  Prophylaxis  of  this  disturbance  is  of 
importance,  and  consists  of  giving  the  nursing  mother 
proper  instructions  as  to  the  nursing,  especially  as  to  its 
frequency,  and  seeing  to  it  that  the  rules  for  nursing,  as 
laid  down  elsewhere,  are  observed  by  the  nursing  mother 
In  wet-nursing,  more  caution  is  necessary,  especially  in 
those  wet-nurses  who  have  an  abundance  of  milk,  which 
is  frequently  the  case  in  a  wet-nurse  whose  own  child  is 
much  older  than  the  infant  to  be  nursed. 

A  very  important  point  to  impress  both  on  the  mother 
and  also  on  the  wet-nurse  is  the  fact  that  crying  of  the 
infant  is  not  always  due  to  hunger,  and  that  offering  the 
breast  should  not  be  used  as  a  means  for  quieting  the 
child. 

When  the  initial  or  mild  symptoms  only  are  present, 
then  correction  of  the  nursing  habits  is  usually  sufficient, 
the  infant  improving  without  any  special  treatment. 

When  the  error  lies  in  too  frequent  nursings,  it  is  best 
and  often  completely  relieved  by  lengthening  the  feed- 
ing intervals  to  three  or,  even  better,  four  hours. 

6 


82  INFANT   FEEDING. 

It  is  of  equal  importance  that  the  infant  should  not  be 
left  too  long  at  the  breast.  The  best  average  nursing  time 
being  about  fifteen  minutes,  with  twenty  minutes  as  the 
maximum.  However,  when  the  flow  of  milk  is  very  free, 
it  may  be  necessary  to  reduce  the  nursing  period  to  even 
three  to  five  minutes,  it  being  a  fact  that  most  infants 
take  about  75  per  cent,  of  their  entire  meals  in  the  first 
five  minutes  at  the  breast.  It  is  always  well  at  the  begin- 
ning of  such  an  experiment  to  weigh  the  baby  after  a 
two,  three,  five,  ten,  and  twenty  minutes  period  to  ascer- 
tain the  exact  amount  which  the  baby  obtains  from  the 
particular  breast  which  it  is  nursing,  so  that  conclusions 
may  be  drawn  definitely  as  to  the  time  it  is  to  be  left  on 
each  breast. 

If  placing  the  infant  at  the  breast  for  short  periods 
with  long  intervals  does  not  give  results,  it  is  advisable 
to  express  the  milk,  and  feed  in  small  quantities  from  the 
bottle.  And  if  another  baby  be  at  hand,  it  may  be  placed 
upon  the  breast  to  keep  up  the  supply.  Or  when  a  wet- 
nurse  is  available  for  temporary  use,  the  babies  may  be 
exchanged. 

Weaning  should  under  all  circumstances  be  considered 
only  as  the  last  resort,  after  all  other  methods  of  adapt- 
ing the  infant  to  the  breast  have  failed. 

An  excessive  amount  of  fat  in  the  milk  is  more  often 
due  to  an  excessive  intake  of  food  in  general  on  the 
mother's  part  than  an  excess  in  any  one  element,  and  can 
be  diminished  best  by  cutting  down  the  food  as  a  whole, 
lessening  the  amount  of  all  food. 

When  the  condition  has  progressed  farther,  and  the 
symptoms  have  become  more  serious,  then  it  is  necessary 
to  treat  the  infant  also.  The  treatment  consists  in  empty- 
ing the  stomach  and  the  bowels  of  the  overload  of  fer- 


NUTRITIONAL   DISTURBANCES.  83 

menting  food,  and  of  rest  for  the  digestive  apparatus, 
both  these  objects  being  achieved  by  giving  a  bland  diet, 
consisting  of  boiled  water  or  weak  tea  sweetened  with 
saccharin,  for  twelve  hours,  the  digestive  tract  getting  rid 
of  its  contents  spontaneously. 

If  the  symptoms  improve  upon  this  treatment,  the 
nursing  should  be  gradually  resumed  by  giving  two 
breast  feedings  in  the  twenty-four  hours  following  the 
period  of  starvation,  substituting  for  the  other  nursings 
bland  liquids,  and  increasing  cautiously  the  number  of 
nursings. 

If  on  withholding  the  food,  vomiting  does  not  cease, 
then  it  is  necessary  to  wash  out  the  stomach. 

Irrigation  of  the  bowel  is  often  necessary,  and  aids  in 
removal  of  fermenting  intestinal  contents,  and  allows 
also  the  gases  to  pass,  thus  relieving  the  distention  and 
colic.  Only  when  change  of  diet  and  irrigation  are  not 
sufficient,  then  the  use  of  purgatives  is  advisable,  castor 
oil  being  just  as  efficient  and  less  harmful  than  the  fre- 
quently preferred  calomel. 

Colic  usually  disappears  on  correction  of  the  diet,  and 
after  the  intestinal  tract  has  been  cleansed  of  its  irritating 
contents,  and  of  gas.  Massage  to  the  abdomen  will  aid 
the  passage  of  gases  which  cause  distention,  when  the 
bowels  tend  to  become  paretic.  In  severe  pain,  warm 
applications  to  the  abdomen  give  relief.  If  these  meas- 
ures fail  to  bring  relief,  and  the  pain  is  such  that  the  in- 
fant is  deprived  of  sleep,  a  mild  sedative  in  small  doses 
may  be  given. 

Feeding  of  powdered  casein  in  amounts  varying  from 
6  to  ^8  Gm.,  dissolved  in  30  to  60  mils  of  water,  two  or 


84  INFANT   FEEDING. 

three  times  daily  will  relieve  colic  in  many  infants,  in 
all  probability  due  to  lessening  of  intestinal  peristalsis. 

There  is  a  class  of  infants  who,  although  they  are  gain- 
ing progressively  in  weight,  cry  a  great  deal,  expel  a 
great  deal  of  gas,  and  perhaps  have  a  green  stool  now  and 
then.  It  is  almost  criminal  to  take  such  infants  off  the 
breast,  although  the  temptation  to  do  so  is  very  great, 
because  of  the  worry  they  cause  the  mother,  and  conse- 
quent harassing  of  the  physician.  Such  an  infant  will 
frequently  cry  for  six,  eight,  ten,  or  twelve  hours  out  of 
the  twenty-four,  and  still  make  a  good  gain  in  weight 
each  week,  in  which  case  it  is  -very  probable  that  the 
infant  is  being  overfed,  and  the  food  supply  should  be 
reduced.  The  mother's  diet  and  general  habits  should 
receive  attention. 

3.  Congenital  Debility,  with  Resulting  Impair- 
ment of  Vital  Functions. 

Etiology.  Premature  birth  is  the  most  important 
condition  causing  debility  associated  with  deficient  func- 
tionating power  of  the  digestive  organs.  Method  of 
feeding  premature  infants  will  be  detailed  later  in  a 
special  chapter. 

Hereditary  weakness  of  the  offspring  caused  by  dis- 
ease in  the  parents  is  frequently  the  cause  of  deficient 
morphological  and  functional  development  of  the  diges- 
tive organs,  and  thus  it  is  often  the  underlying  cause  of 
nutritional  disturbances,  which  are  more  commonly 
chronic  in  character.  Tuberculosis,  syphilis,  and  alco- 
hoHsm  in  parents  stand  at  the  head  of  the  conditions 
causing  hereditary  weakness,,  even  when  the  oft'spring 
does  not  inherit  the  disease  itself. 


NUTRITIONAL    DISTURBANCES.  85 

Malformations  of  the  digestive  tract  (cleft  palate, 
sublingual  tumors,  pyloric  stenosis,  atresias  of  the  intes- 
tinal tract,  Hirschprung's  disease,  etc.)  from  any  cause 
compromise  its  functional  capacity  usually,  but  in  most 
cases  they  cause  serious  conditions  necessitating  surgical 
interventions,  and  only  rarely  do  they  produce  simple 
nutritional  disturbances  amenable  to  dietetic  means,  and 
therefore  they  belong  to  the  domain  of  surgery. 

Symptoms.  As  may  be  expected,  symptoms  of  these 
so  diverse  conditions  vary.  Hereditary  weakness  may 
often  be  suspected  when  symptoms  of  nutritional  dis- 
turbances develop  even  when  the  infant  is  given  the  best 
care  possible,  and  the  milk  is  quantitatively  and  quali- 
tatively correct.  Symptoms  of  underfeeding  or  of  over- 
feeding, as  described  previously,  may  be  present,  de- 
pending upon  the  etiological  factor. 

Diagnosis.  Careful  examination  for  malformations, 
and  thorough  family  history,  in  cases  of  suspected 
hereditary  weakness  are  of  chief  importance  in  making 
the  etiological  diagnosis. 

Treatment  is  usually  determined  by  the  pathology, 
and  by  the  nature  of  the  particular  nutritional  disturb- 
ance which  developed. 

4.  Intercurrent  Parenteral  and  Enteral  Infections. 

Etiology.  Diseases  both  in  the  mother  and  in  the 
infant  are  to  be  considered  in  etiology  of  this  condition. 
In  the  mother  the  most  important  are  the  general  infec- 
tious diseases,  e.g.,  puerperal  fever  and  sepsis,  typhoid, 
pneumonia,  etc.,  and  local  infections  of  the  breast,  and 
also  of  the  upper  respiratory  passages.  In  the  infant 
there  are  parenteral  infections,  that  is,  infections  outside 
the    digestive    tract,    e.g.,    pharyngitis,    tonsillitis,    pneu- 


86  INFANT   FEEDING. 

monia,  pyelitis,  bronchitis,  and  enteral  infections,  or  in- 
fections of  the  intestinal  tract,  which  will  be  discussed 
under  a  special  heading. 

Symptoms.  In  the  conditions  dependent  on  the 
mother's  health  the  symptoms  will  vary  first  with  the 
quality  and  quantity  of  her  milk  supply,  which  will  have 
an  effect  on  the  child's  general  nutrition,  and,  secondly, 
may  result  in  direct  parenteral  or  enteral  infections  of 
the  infant. 

In  those  dependent  on  infections  of  the  infant  itself  we 
invariably  find  evidences  of  nutritional  disturbances, 
whether  the  infection  be  local,  systemic,  or  confined  to 
the  intestinal  tract.  The  clinical  picture  varies  directly 
with  the  degree  of  disturbance  of  the  metabolic  function. 
While,  as  a  rule,  the  enteral  infections  are  more  com- 
monly associated  with  grave  disturbances  of  the  infant's 
nutrition,  it  is  not  uncommon  to  find  the  infant  severely 
aft'ected  in  its  ability  to  m*eet  its  nutritional  needs  by 
the  parenteral  infections.  While  any  one  of  the  above 
enumerated  etiological  factors  may  give  rise  to  a  marked 
clinical  picture,  it  is  to  be  remembered  that  this  class  of 
disturbances  in  the  breast-fed  infants  are  of  minor  im- 
portance as  compared  with  those  of  the  artificially  fed 
(see  Nutritional  Disturbances  in  Artificially  Fed  In- 
fants). 

Diagnosis.  The  diagnosis  of  the  primary  seat  of  in- 
fection in  the  infant  is  of  considerable  importance  in  de- 
ciding the  method  of  treatment. 

Treatment.  Parenteral  infections  rarely  call  for  re- 
straint in  administration  of  food  because  of  the  asso- 
ciated anorexia,  and  the  infant  should  be  nursed  (if  pos- 
sible without  danger  to  the  mother)  directly  at  her 
breast. 


NUTRITIONAL    DISTURBANCES.  87 

In  the  case  of  enteral  infections  it  may  be  necessary  to 
withdraw  the  maternal  milk  and  replace  it  by  a  short 
period  of  starvation,  to  be  followed  by  small  quantities  of 
breast  milk,  either  taken  directly  from  the  breast  during 
short  nursings,  or  it  may  be  best  to  feed  small  quantities 
of  expressed  milk  to  the  infant  at  regular  intervals. 

Not  infrequently  it  becomes  necessary  to  feed  these 
infants  by  catheter  in  order  to  sustain  them.  And  this 
method  of  introducing  their  food  should  be  begun  suffi- 
ciently early  to  avoid  a  catastrophe. 

Under  no  circumstances  should  they  be  placed  upon 
food  other  than  the  mother's  milk  when  her  state  of 
health  and  the  quality  of  her  milk  permit. 

Inert  fluids,  such  as  water,  weak  tea,  broths  made  from 
young  meats  and  young  fowls,  and  cereal  decoctions 
should  be  given  between  feedings  to  insure  a  sufficient 
intake  of  water.  A  careful  record  should  be  kept  of  the 
twenty-four-hour  quantity  of  all  fluids  administered,  in 
order  to  insure  the  child  a  sufficient  water  and  food  ad- 
ministration. 

For  conditions  in  the  mother  which  would  justify 
weaning,  see  chapter  on  Weaning  and  Contraindications 
to  Nursing. 

5.  Idiosyncrasy  Towards  Mother's  Milk. 

Etiology.  This  condition  is  very  rare,  although  it 
may  not  be  denied  that  it  exists.  The  etiology  and  patho- 
genesis are  as  yet  little  understood. 

Diagnosis.  The  diagnosis  of  this  disturbance  should 
be  made  by  exclusion  of  all  other  causes  that  may  give 
rise  to  a  similar  symptom-complex.  It  may  be  confirmed 
by  the  change  of  the  milk  either  by  substituting  a  wet- 


88  INFANT   FEEDING. 

nurse  or  cow's  milk  for  maternal  nursing,  whereupon  the 
symptoms  improve. 

Treatment.  The  treatment  depends  upon  the  par- 
ticular symptom-complex  which  develops.  Change  of 
milk  is  imperative  in  cases  in  which  idiosyncrasy  is 
clearly  established.  The  mother's  milk  should  not  be  al- 
lowed to  dry  up  during  the  period  of  experimentation, 
because  of  the  possibility  of  an  error  in  diagnosis. 


CHAPTER    VII. 

METHODS    OF    FEEDING    PREMATURE 
INFANTS. 

1.  Infants  Nursing  at  the  Breast. 

In  most  cases  we  do  not  feed  the  more  developed  pre- 
mature infant  on  the  first  day.  It  may  be  wise,  however, 
to  place  the  infant  on  the  breast  two  or  three  times  dur- 
ing the  last  half  of  the  first  day,  after  the  circulatory  and 
respiratory  functions  are  well  established,  so  that  the  in- 
fant may  become  accustomed  to  nursing.  We  are  now 
confronted  with  two  important  factors,  first,  the  ability 
of  the  infant  to  nurse  the  breast;  and  secondly,  sufficient 
and  proper  development  of  the  nipples  to  allow  of  the 
infant's  properly  grasping  the  same.  If  the  infant  is 
sufficiently  developed  to  take  hold  of  a  well-formed 
nipple,  it  should  be  placed  at  the  mother's  breast  regularly 
at  three-hour  intervals  on  the  second  day,  for  two-  or 
three-  minute  periods,  even  though  there  is  little  hope 
of  the  breasts  secreting  at  this  time.  By  this  means  the 
infant  is  trained  to  expect  its  food  at  regular  periods, 
and  at  the  same  time  the  maternal  breast  is  stimulated. 
When  a  wet-nurse  can  be  supplied  in  the  home  who  has 
her  own  infant  with  her,  the  latter  can  be  used  to  stimu- 
late the  breasts  of  the  mother,  and  the  new  infant  can 
have  one  of  the  wet-nurse's  breasts  set  aside  for  its  use. 
Where  the  infant  is  very  weak,  the  breast  set  aside  for  it 
can  be  made  to  secrete  more  freely  by  simultaneously 
placing  the  wet-nurse's  baby  on  the  opposite  breast  dur- 
ing the  period  of  nursing. 

(89) 


90  IXFAXT   FEEDING. 

We  have  found  this  to  be  a  very  valuable  expedient. 
However,  with  this  latter  method  of  procedure  the  quan- 
tity taken  by  the  premature  infant  must  be   accurately 
measured  to  prevent   overfeeding   by   weighing   the   in- 
fant before  and  after  the  nursing  period.     Nursing  di- 
rectly from  the  breast  has  the  added  advantage  of  de- 
veloping  the    baby's    sucking   muscles,    preventing    con- 
tamination of  the  milk,  and  stimulating  the  breasts  by 
the  natural  method.    It  should,  however,  be  remembered 
that  a  weak  infant  may  nurse  the  maternal  breast  for  a 
considerable  time,  and  yet  the  amount  of  food  taken  may 
be  insufficient.    This  is  especially  true  of  that  class  of  in- 
fants who  are  inclined  to  go  to  sleep  at  the  breasts.   Here, 
again,  weighing  is  of  the  utmost  importance.    When  the 
infant   is   too   weak   to   nurse    sufficiently   to   satisfy   its 
needs,  as  ascertained  by  weighing,  the  nursing  should  be 
followed  by  substitute  feeding  with  expressed  milk,  either 
by  the  bottle  or  one  of  the  other  methods  to  be  described. 
These  rules  do  not  apply  for  the  first  and  second  day, 
when  only  rarely  more  than  four  or  five  meals  should  be 
given.     In  very  weak  infants,  and  those  subject  to  re- 
gurgitation after  taking  small  quantities  of  milk,  it  may 
be  necessary  to  feed  more  frequently  in  periods  varying 
from  two  to  two  and  a-half  hours,  as  may  be  indicated 
by  the  quantity  retained,  or  better  results  may  be  obtained 
by  catheter  feeding   (to  be  described  later)    with   four- 
hour  intervals. 

2.  Infants  Too  Weak  to  Nurse  the  Breasts. 

In  this  class  of  infants,  wherever  possible,  they  should 
be  fed  without  being  removed  from  their  bed  or  the  in- 
cubator, if  used,  so  as  to  avoid  all  careless  exposure  of 


FEEDING    PREMATURE    INFANTS.  91 

the  infant.  The  cause  of  inability  to  nurse  may  be  due 
to  several  factors:  (1)  Infants  unable  to  swallow;  this 
is  usually  because  of  improper  development  of  the  center 
in  the  medulla,  or  lack  of  co-ordination  on  the  part  of 
the  pharyngeal  muscles  and  tongue.  This  is  usually  made 
evident  by  the  milk  flowing  from  the  dependent  part  of 
the  mouth.  In  such  cases  it  is  generally  necessary  to  re- 
sort to  catheter  feeding.  (2)  Those  too  weak  to  nurse, 
and  who  may  appear  to  be  almost  dead ;  in  this  class  there 
is  great  danger  in  handling  the  infant,  and  it  is  best  fed 
in  the  bed.  (3)  Those  who  will  not  suck.  (4)  Those 
vomiting  after  every  feeding.  (5)  Those  becoming 
cyanotic  after  feeding.  In  the  latter  cases  it  may  even  be 
necessary  to  resort  to  such  methods  as  gentle  friction, 
artificial  respiration,  best  performed  by  gently  compress- 
ing the  thorax,  warm  baths,  oxygen,  etc. 

Methods.  One  of  the  following  methods  can  be  se- 
lected for  feeding  these  infants : 

1.  The  nasal  spooyi,  which  can  be  used  either  by  pour- 
ing the  milk  slowly  into  the  nose  or  into  the  mouth.  The 
latter  is  to  be  preferred,  because  of  the  dangers  due  to 
decomposition  of  the  milk  in  the  nose  and  naso-pharynx, 
with  secondary  development  of  rhinitis  and  pharyngitis. 

2.  A  medicine  dropper  for  mouth  feeding.  This  is 
possibly  one  of  the  best  methods  for  feeding  this  class 
of  infants,  as  it  is  simple  of  application,  and  a  small 
dropper  is  easily  obtainable.  As  in  all  other  methods,  the 
food  should  be  administered  very  slowly. 

3.  Nursing  From  a  Bottle.  For  this  purpose  the  small 
nipples  commonly  sold  on  doll  nursing-bottles  are  of  the 
proper  size,  and  can  usually  be  obtained  of  proper  quality. 
We  have  not  infrequently  perforated  the  rubber  end  of 
a  medicine  dropper  and  used  it  for  this  purpose.     The 


92 


INFANT    FEEDING. 


bottle  to  be  used  can  either  be  an  ordinary  1-ounce  or  2- 
ounce  medicine  bottle,  or,  better,  the  special  bottle  which 
was  designed  by  the  author  for  this  purpose.    This  bottle 


-4 

—  3 

—  Z 


Fig.  5. — Breck  feeder  for  premature  infants. 


holds  2  ounces  of  milk,  is  graduated  in  cubic  centimeters, 
has  a  ground  glass  neck  which  coapts  perfectly  with  the 
bulb  on  the  special  breast-pump,  and  which  after  being 
filled  is  corked  with  a  ground  glass  stopper,  and  which 
has  the  added  advantage  in  that  the  milk  is  in  no  way 
handled  after  it  leaves  the  breast. 


FEEDING   PREMATURE   INFANTS.  93 

4.  The  Breck  Feeder.  This  has  the  added  advantage 
that  the  milk  can  be  passed  into  the  pharynx  without 
effort  on  the  part  of  the  child  when  it  is  too  weak  to 
nurse.  This  has  the  one  disadvantage  of  too  rapid  feed- 
ing if  not  properly  controlled. 

5.  A  rather  slow  but  satisfactory  method  of  feeding 
the  infants  is  by  expressing  the  milk  directly  from  the 
nipple  into  the  infant's  mouth  during  the  feeding  period. 

6.  Catheter  Feeding  by  Mouth  (gavage).  For  this 
purpose  a  small  funnel  is  attached  either  directly  or  by 
means  of  a  short  piece  of  rubber  tubing  with  a  glass 
connection  to  rubber  catheter.  A  Nelaton  catheter  is 
used  (best  a  No.  14  French),  about  25  to  40  cm.  long 
(10  to  16  inches),  marked  in  centimeters  or  inches,  so 
that  at  all  times  its  position  can  be  estimated.  The  in- 
fant should  be  fed  in  the  incubator,  its  crib,  or  on  the 
dressing  table.  Its  head  should  be  slightly  lower  than 
the  body.  The  passage  of  the  catheter  is  usually  effected 
without  difficulty  by  grasping  it  as  one  would  a  pen,  and 
passing  it  in  the  midline  to  the  pharynx,  gradually  push- 
ing it  into  the  esophagus.  This  is  usually  accomplished 
without  difficulty,  because  of  the  poorly  developed 
pharyngeal  reflexes,  and  rarely  results  in  retching  or 
vomiting.  In  infants  who  retch  during  the  passage  of 
the  catheter,  vomiting  may  be  expected  because  of  the 
fact  that  these  latter  infants  not  infrequently  belong  to 
the  spasmophilic  group.  The  danger  of  passing  the 
catheter  into  the  larynx  is  minimal.  It  is  rarely  necessary 
to  pass  the  catheter  more  than  10  centimeters  (4  inches) 
beyond  the  infant's  lips,  and  we  have  found  it  equally  as 
practical  to  limit  the  passage  of  the  catheter  to  7.5  centi- 
meters (3  inches).  In  most  instances  this  does  not  reach 
the  stomach,  but  has  the  added  advantage  of  preventing 


94 


INFANT   FEEDING. 


trauma  to  the  cardiac  end  of  the  stomach  and  the  gas- 
tric mucosa.  When  a  graduated  catheter  is  not  at  hand, 
it  may  be  marked  at  10  centimeters  with  indehble  ink, 
and  this  used  as  the  maximum  point  for  passage.     A 


Fig.  6. — Apparatus  for  gavage  and  lavage.  (Glass  taken 
from  Breck  feeder.)  When  using  for  small  infants  the 
catheter  should  be  attached  directly  to  the  funnel  without 

the  intervening  rubber  tube. 

fairly  safe  maximum  for  the  passage  of  the  catheter  can 
be  ascertained  by  measuring  the  distance  from  the  glab- 
ella to  the  epigastrium  in  the  individual  infant.  The  de- 
sired quantity  of  milk  is  allowed  to  flow  into  the  stom- 


FEEDING    PREMATURE    INFANTS. 


95 


ach,  slowly,  by  raising  the  funnel  only  very  slightly  above 
the  level  of  the  body.  After  feeding,  the  catheter  is 
firmly  compressed  to  avoid  all  leakage  into  the  pharynx, 
and  the  catheter  then  removed,  but  not  too  rapidly.    The 


Fig,  7. — Introduction  of  catheter  for  gavage. 


milk  to  be  fed  should  be  measured  in  a  graduated  glass, 
and  the  latter  kept  close  at  hand  in  order  that  the  amount 
given  can  at  all  times  be  estimated. 

A  complete  record  of  every  feeding,  both  as  to  the 
time  and  the  amount,  should  be  kept.  This  is  especially 
important  in  institutions  where  the  nurses  have  a  number 
of  infants  to  observe,  and  is  greatly  facilitated  by  a  time- 


96  INFANT   FEEDING. 

clock  registering  the  day,  hour,  and  minute  of  each  feed- 
ing. The  nurse  records  the  quantity  of  milk  taken,  which 
in  breast-fed  infants  is  obtained  by  weighing  the  infant 
both  before  and  after  feeding  on  an  accurate  scale,  or  in 
infants  too  weak  to  nurse  by  measuring  the  quantity  in 
a  graduated  glass  before  feeding. 

3.  Proper  Time  for  Beginning  Regular  Feeding. 

Due  to  the  tendency  toward  the  rapid  development  of 
acute  inanition  in  this  class  of  infants,  the  greatest  dan- 
ger is  that  of  too  long  delay  in  establishing  regular  feed- 
ing. Therefore  it  is  often  impossible  to  wait  for  the 
mother's  milk  to  appear.  We  believe  that  it  is,  however, 
unwise  in  most  instances  to  attempt  to  feed  with  milk 
during  the  first  twelve  to  twenty-four  hours,  rather  pre- 
ferring to  allow  the  circulatory  and  respiratory  organs 
opportunity  for  proper  accommodation  to  their  new  en- 
vironment. During  this  time  the  loss  of  body  fluids 
through  evaporation  from  the  skin  and  respiratory  tract 
due  to  the  warmth  of  the  incubator,  and  the  excretions 
through  the  kidneys  and  bowels,  should  be  recompensed 
by  the  regular  administration  of  water  or  some  other 
inert  fluid. 

We  have  endeavored  to  administer  about  one-sixth  of 
the  body  weight  of  water  (inclusive  of  that  contained  in 
the  milk  if  given)  in  twenty-four  hours. 

In  smaller  infants  the  first  milk  is  given  diluted  one 
to  four  times  during  the  first  four  days.  After  the  first 
twenty-four  hours  water  can  be  administered  partly  with 
the  food,  and  otherwise  between  feedings.  If  for  any 
reason  the  water  is  not  w^ell  retained  when  given  by 
mouth,  it  can,  at  least  in  part,  be  administered  by  rectum. 


FEEDING    PREMATURE    INFANTS.  97 

Example:  An  infant  weighing  about  1200  grams  should 
receive  200  mils  of  water;  should  this  infant  receive  50 
mils  of  milk,  this  can  be  diluted  with  50  mils  or  more  of 
water  or  sugar  solution,  and  the  remaining  100  mils  ad- 
ministered between  feedings.  If  a  stimulant  is  indicated, 
a  few  drops  of  brandy  (6  to  15  in  twenty-four  hours) 
may  be  added  to  the  water  or  sugar  solution  during  the 
first  twenty-four  hours.  Half  strength  of  Ringer's  solu- 
tion prepared  as  follows  can  be  used  to  good  advantage 
for  rectal  administration: 

NaCl   7.5  Gm.' 

KCr 0.1     " 

CaCl   0.2     " 

Water  ' 1000.0  mils. 

We  have  made  it  a  rule  never  to  start  milk  feeding 
until  after  the  first  bowel  movement.  Not  infrequently 
the  removal  of  meconium  may  be  accomplished  by  the 
administration  of  a  small  quantity  of  physiological  salt 
solution  through  a  catheter  passed  one  or  two  inches 
into  the  rectum.  This  is  done  to  remove  the  meconium 
before  infection  of  the  intestinal  tract  through  the 
administration  of  food.  Occasionally  it  is  necessary 
to  administer  5  drops  of  castor  oil  to  obtain  slight 
purgation. 

4.  Feeding  From  the  Second  to  the  Tenth  Day. 

It  must  be  remembered  that  the  general  rules  as  ap- 
plied to  the  feeding  of  premature  infants  do  not  hold 
for  the  first  ten  days  of  life.  The  early  feedings  must 
necessarily  be  small,  and  the  increases  gradual.  Two 
grave  dangers  present  themselves  during  the  first  period 
of  the  infant's  existence:    (1)  overfeeding  and  (2)  star- 

7 


98  IXFAXT    FEEDING. 

vation,  the  latter  usually  resulting  from  an  inability  to 
supply  sufficient  quantity  of  human  milk,  following  an 
attempt  to  await  the  natural  secretion  of  the  mother's 
breast.  Overfeeding  results  either  in  vomiting  or,  more 
seriously,  in  stomach  distention,  which  leads  to  asphyxia 
and  cyanosis.  Underfeeding  in  these  weak  infants  soon 
leads  to  inanition.  From  the  second  day  these  infants 
should  be  fed  regularly  day  and  night,  every  two  or, 
better,  three  hours,  depending  upon  the  infant's  condition 
and  the  method  of  food  administration.  Not  infre- 
quently where  the  quantities  taken  are  very  small,  ten  to 
twelve  feedings  are  required  in  twenty-four  hours.  It 
may  even  be  necessary  in  very  weak  infants  to  feed 
minimal  quantities  every  hour.  The  question  of  the 
number  of  feedings  will  be  discussed  in  detail  later. 

It  is  practically  impossible  to  formulate  definite  rules 
for  feeding  premature  infants  during  the  first  ten  days, 
because  of  their  great  variation  in  weight  and  develop- 
ment. Therefore  it  becomes  necessary  to  feed  each  in- 
fant indiz'iduaUy. 

During  the  first  days  it  is  often  difficult  in  infants 
weighing  1000  to  1200  grams  or  less  to  feed  more  than 
20  to  50  mils  of  milk  per  day,  and  it  may  be  necessary  to 
limit  the  food  to  this  quantity  during  the  first  ten  days. 
It  is  our  rule  to  start  feedings  in  this  class  of  cases  with 
a  maximum  of  4  mils  per  feeding,  not  infrequently  using 
one-fourth  or  one-half  human  milk  at  the  start,  and  the 
balance  water. 

The  feedings  should  be  increased  by  1  mil  at  a  time, 
and  with  the  first  evidence  of  regurgitation  the  quantity 
should  remain  stationary.  Even  in  favorable  cases  dur- 
ing this  time  30  to  50  calories  per  kilogram  is  likely  to 
be  the  maximum  that  can  be  fed  with  impunity. 


FEEDING   PREMATURE   INFANTS.  99 

The  small  feedings  which  can  be  assimilated,  and  the 
low  energy  quotient  during  the  first  two  or  three  weeks, 
must  be  considered  physiological,  and  as  we  rarely  see 
an  increase  in  weight  with  feedings  of  less  than  90  cal- 
ories per  kilogram,  we  are  confronted  by  a  rapid  loss  in 
body  weight  during  the  first  days  of  life.  In  favorable 
cases  this  is  usually  followed  by  a  stationary  weight,  or 
moderate  fluctuations  after  the  first  four  to  seven  days. 
Occasionally  an  infant  is  seen  in  whom  there  is  sufficient 
water  retention  to  avoid  most  of  the  initial  loss  in  weight. 
One  should,  therefore,  remember  that  even  with  fre- 
quent feedings  with  human  milk,  either  at  the  breast,  by 
hand,  or  gavage,  it  is  rarely  possible  to  feed  more  than 
the  minimum  requirements  without  causing  vomiting. 

5.  Feeding  After  the  First  Ten  Days. 

There  has  been  considerable  discussion  as  to  the  food 
requirements  of  premature  and  underweight  infants 
during  the  past  few  years.  Budin  gives  us  the  rule  that 
premature  infants  of  less  than  2500  grams  after  their 
tenth  day  require  one-fifth  of  their  body  weight  (200 
Gm.  per  kilogram  of  body  weight),  or  140  calories,  while 
the  full-term  infant  of  normal  development  requires  one- 
seventh  of  its  body  weight  (140  Gm.  per  kilogram  body 
weight),  or  100  calories  per  day.  On  the  other  hand, 
Birk  believes  that  the  more  fully  developed  premature 
infant,  and  those  nearing  the  normal,  will  thrive  on  one- 
sixth  to  one-seventh  of  their  body  weight. 

Our  opinion,  based  on  a  series  of  experiments  made 
on  a  number  of  premature  infants,  is  that  they  require 
higher  food  values,  or  at  least  the  maximum  required  by 
normal    infants,    for    the    following    reasons:     (1)    the 


100  INFANT   FEEDING. 

greater  body  surface  as  compared  with  the  body  weight; 
(2)  in  the  normal  infant  the  requirements  decrease  with 
the  age,  and  therefore  in  the  premature  the  quantity  re- 
quired varies  inversely  with  the  fetal  age  after  the  first 
weeks  of  life;  (3)  the  need  for  body  development  is 
relatively  greater  in  the  premature  than  in  the  full-term 
infant;  (4)  a  kilogram  of  body  weight  in  the  fat-poor 
premature  infant  cannot  be  taken  as  parallel  in  feeding 
to  the  well  developed  full-term  infant,  with  its  prepon- 
derance of  fatty  tissue.  This  latter  point  must  also  be 
considered  in  the  feeding  of  the  marasmic  infant,  to 
obtain  a  proper  gain  in  weight  as  compared  with  the 
lower  requirements  in  the  fat,  full-term  infant. 

6.  Number  of  Feedings  Daily. 

Our  own  experience  has  led  us  to  adopt  a  conservative 
position  in  that  we  have  grouped  the  infants  nursed  at 
the  breast  or  fed  from  the  bottle  or  by  feeders  into  two 
general  classes:  (1)  those  weighing  under  1500  Gm., 
and  (2)  those  above  this  figure,  based  on  the  tendency 
of  the  smaller  infants  to  become  exhausted  when  the 
feedings  are  long  continued.  The  former  are  fed  at  2- 
hour  intervals  during  the  day,  and  3-hour  intervals  at 
night,  as  follows:  6  a.m.,  8  a.m.,  10  a.m.,  12  m.,  2  p.m., 
4  P.M.,  6  P.M.,  9  p.m.,  12  P.M.,  and  3  a.m. — 10  feedings 
during  the  twenty-four  hours.  The  larger  infants  are 
fed  on  a  3-hour  basis,  8  feedings  being  given  during  the 
twenty-four  hours.  These  figures  should  in  no  way  be 
construed  as  arbitrary.  All  feedings  are  more  or  less 
dependent  upon  the  general  development  of  the  infant  in 
relation  to  its  digestion  and  metabolism,  its  retention, 
and  upon  the  larger  quantities  of  food  necessarily  given 
to  meet  its  nutritional  requirements,  and  a  careful  atten- 


FEEDING   PREMATURE   INFANTS.  101 

tion  to  gastric  distention,   regurgitation,   asphyxia,  cya- 
nosis, and  other  respiratory  complications. 

It  has  been  our  personal  experience  to  meet  with  con- 
siderable difficulty  in  attempting  to  meet  the  large  food 
requirements  in  smaller  infants  without  resorting  to 
catheter  feeding.  In  these  we  have  adopted  the  longer 
interval  between  feedings,  of  four  hours  with  six  feed- 
ings in  twenty-four  hours,  the  individual  meal  in  catheter 
feeding  being  greater  in  quantity.  Notwithstanding  the 
fact  that  catheter  feeding  offers  little  difficulty  and  few 
dangers  in  experienced  hands,  this  may  not  be  true  with 
those  not  skilled  in  its  use.  A  considerable  number  of 
our  cases  have,  however,  thrived  satisfactorily  on  quan- 
tities of  milk  less  than  one-fifth  of  their  body  weight  per 
day,  and  one  should  always  remember  that  it  is  a  safe 
axiom  not  to  force  the  feeding  in  these  cases  as  long  as 
their  general  development  is  progressing  satisfactorily 
and  their  weight  curve  is  good. 

7.  The  Amount  of  each  Feeding. 

The  statistics  as  to  the  stomach  capacity  for  food  in 
premature  infants  indicate  that  this  varies  within  con- 
siderable limits,  even  in  infants  of  the  same  fetal  age,  as 
does  also  their  ability  to  digest  and  assimilate  food. 
The  weight  and  length,  naturally  excluding  congenital 
diseases  and  deformities,  will  be  far  more  dependable  as 
a  guide  to  stomach  capacity  than  the  fetal  age.  As  no 
definite  rules  can  be  established  governing  the  amounts 
of  individual  feedings,  we  begin  with  what  could  be 
considered  minimum  quantities  and  gradually  increase 
the  amount  of  feedings  as  the  infant  develops  an  ability 
to  digest  it.  It  is  our  rule,  as  previously  stated,  during 
the  first  few  days  to  feed  small  total  quantities  varying 


102  INFANT   FEEDING. 

from  20  to  50  mils  of  milk  per  day,  dividing  these  totals 
by  the  number  of  feedings  to  be  administered  (eight  to 
ten),  thereby  feeding  from  2  to  6  mils  of  milk  per  feed- 
ing. The  feedings  can  then  be  increased  by  1  or  more 
mils  at  a  time,  and  in  the  absence  of  vomiting  the  in- 
dividual feedings  can  be  increased  more  or  less  rapidly 
until  the  weight  loss  ceases  or  an  increase  in  weight  oc- 
curs. Even  in  favorable  cases,  weighing  over  1500  Gm., 
45  to  75  mils  per  kilogram  weight  (30  to  50  calories  per 
kilogram)  is  likely  to  be  the  maximum  that  can  be  fed 
with  impunity  or  safety  during  the  first  ten  days. 

8.  Daily  Gains. 

These  are  not  necessarily  in  proportion  to  the  changing 
quantity  of  milk  administered,  as  many  factors,  such  as 
condition  of  the  bowels,  quantity  of  the  urine  passed, 
temperature  of  the  infant's  surroundings,  will  neces- 
sarily influence  the  weight.  This  is  more  especially 
noticeable  in  observations  continued  during  a  short  period 
of  time.  An  average  greater  daily  gain  than  20  Gm. 
is  unusual  when  the  infant's  food  is  limited  to  one-fifth 
of  its  body  weight.  An  average  of  from  10  to  20  Gm. 
daily  can  in  most  cases  be  considered  satisfactory. 

9.  Artificial  Feeding. 

There  can  be  no  comparison  between  the  results  to  be 
expected  in  feeding  premature  infants  on  human  milk, 
and  those  to  be  obtained  with  artificial  food.  With 
human  milk  taken  from  a  well  regulated  department  for 
wet-nurses  the  milk  can  be  obtained  fresh,  practically 
sterile ;  it  is  more  digestible ;  its  constituents  are  of  the 
quality  and  in  the  proportions  required  for  the  growth 
and  development  of  the  human  body;  and  it  is  live,  and 


FEEDING   PREMATURE   INFANTS.  103 

contains  many  of  the  immunity-conferring  properties,  as 
evidenced  by  the  resistance  of  a  breast-fed  infant  to  in- 
fections and  contagious  diseases.  Most  of  these  proper- 
ties and  advantages  are  lacking  in  the  dead  foods  used 
in  artificial  feeding.  Therefore,  if  it  becomes  necessary 
to  resort  to  artificial  feeding,  the  selection  of  the  food, 
its  preparation,  and  its  adaptation  to  the  infant  must  all 
be  given  the  most  painstaking  consideration.  Many 
varieties  of  artificial  diet  have  been  suggested  by  various 
authors,  such  as  simple  milk  dilutions,  cream  and  top- 
milk  mixtures,  skim  and  buttermilk  mixtures,  malt  soup 
preparations,  condensed  and  evaporated  milk,  etc.  The 
results  with  the  various  diets  are  to  a  great  degree  de- 
pendent upon  the  physician's  intimate  understanding  of 
and  directions  for  the  use  of  the  individual  food. 

Quantity  of  Food.  It  must  be  remembered  that  the 
figures  quoted  for  feeding  on  breast  milk  are  the  maxi- 
mum that  can  be  assimilated,  and  in  most  instances  these 
amounts  more  than  fulfil  the  immediate  needs  of  the 
infant's  existence,  and  can  be  considered  (and  in  most 
instances  would  be)  excessive  quantities  for  artificial 
feeding  in  the  first  few  weeks  of  life,  because  of  the 
greater  difficulty  in  the  digestion  of  cow's  milk.  One 
hundred  calories  per  kilogram  is  the  maximum  quantity 
that  can  be  digested  by  most  premature  infants,  and  in 
many  instances  one  must  be  satisfied  with  a  sustaining 
diet  bordering  on  70  to  80  calories,  and  they  must  at  all 
times  be  closely  watched  for  evidence  of  overfeeding,  as 
it  is  dangerous  to  exceed  the  actual  food  requirements, 
and  the  first  evidence  of  digestive  disturbances  or  of  in- 
tercurrent infections  should  lead  to  the  feeding  of  human 
milk.  During  the  first  days  the  same  rules  for  minimal 
feedings  must  be  observed  as  in  feeding  with  breast  milk. 


104  INFANT   FEEDING. 

Quality  of  Food.  Opinions  vary  greatly  as  to  the 
best  food  for  an  artificial  diet.  Ordinary  milk,  water 
and  sugar  mixtures  are  rarely  well  taken.  Pfaundler  sug- 
gests rich  fat  and  low  protein  milk  mixtures ;  but  in  this 
feeding  we  have  seen  fat  diarrhea  resulting.  Budin  ob- 
tained the  best  results  with  peptonized  boiled  milk,  using 
fresh  pancreatic  extracts  for  this  purpose.  Finkelstein, 
Oberwarth,  Birk,  Neumann,  Von  Reuss  have  obtained 
their  best  results  through  the  use  of  boiled  buttermilk 
mixtures,  prepared  according  to  the  following  formulae: 

Buttermilk 1000 

Flour   10 

Sugar 40 

The  above  being  used  for  the  first  feedings. 

Buttermilk   1000 

Flour   15 

Sugar   60 

For  later  feedings. 

Dextrin-maltose  compounds  can  be  substituted  for  the 
cane-sugar  if  desirable. 

Chymogen  or  pegnin  milk  has  given  us  most  satis- 
factory results  in  the  artificial  feeding  of  the  premature 
infants.  This  latter  preparation  is  little  more  than 
a  boiled  milk  in  which  the  curds  are  precipitated  in 
a  fine,  flocculent  form,  about  the  size  of  that  of  human 
milk,  before  it  is  fed  to  the  infant.  It  is  best  diluted  be- 
fore use.  This  preparation  should  be  started  with  1  part 
chymogen  milk  and  3  parts  water,  following  the  direc- 
tions for  increases  in  quantity  and  quality  as  given  for 
human  milk.  Because  of  the  low  carbohydrate  content 
of  such  mixtures,  0.5  per  cent,  of  lactose  should  be 
added  after  the  first  few  days,  and  the  amount  gradually 
increased  to  3  per  cent. 


FEEDING   PREMATURE   INFANTS.  105 

When  even  only  insufficient  amounts  of  human  milk 
can  be  obtained,  artificial  feeding  should  be  used  as  a 
supplement  and  not  as  a  substitute. 

10.  Conclusions. 

1.  The  weight,  temperature,  stools,  absence  of  ab- 
dominal distention,  cyanosis  and  well-being  of  the  infant 
should  be  the  guide  for  increase  in  the  infant's  diet. 

2.  The  utmost  care  is  necessary  in  increasing  the  diet 
of  the  infant  during  the  first  days  of  life.  The  gastro- 
intestinal tract  offers  the  best  evidence  for  increases. 
\^omiting  and  abdominal  distention  and  associated  cya- 
nosis are  the  prime  indications  for  stationary  or  de- 
creased amounts  of  feeding. 

3.  An  initial  weight  loss  during  the  first  ten  days  must 
be  considered  physiological. 

4.  These  infants,  therefore,  should  be  fed  small  quan- 
tities, frequently  repeated,  every  two  to  three  hours  dur- 
ing the  day  and  night. 

5.  On  the  first  day  following  the  first  bowel  evacuation 
the  human  milk  may  be  fed  diluted  with  one  or  two 
parts  of  water  and  sugar,  with  a  caloric  value  approxi- 
mating 15  to  30  calories  (20  to  40  mils,  %  to  1%  ounce 
of  human  milk  to  the  kilogram  of  body  weight). 

6.  From  the  second  day  on,  in  the  absence  of  indiges- 
tion, the  food  may  be  increased  by  10  calories  daily  per 
kilogram  (15  mils  daily  per  kilogram).  In  the  presence 
of  digestive  disorders  greater  care  is  necessary  to  main- 
tain the  metabolic  equilibrium  (120  mils,  4  ounces  of 
milk  to  the  kilogram  of  body  weight). 

7.  It  is  of  the  greatest  importance  to  administer  a 
sufficient  supply  of  water  to  counterbalance  the  rapid 
evaporation  due  to  artificially  heated  and  dried  air    and 


106  INFANT   FEEDING. 

the  excessive  excreta,  more  especially  during  the  first 
few  days.  About  one-sixth  of  the  body  weight  of  water, 
inclusive  of  that  contained  in  the  milk,  should  be  fed  in 
twenty-four  hours. 

8.  It  is  to  be  remembered  that  a  standstill  in  the  weight- 
curve,  and  indigestion  with  bad  bowel  movements,  fre- 
quently result  when  140  calories  per  kilogram  are 
exceeded. 

9.  All  intestinal  disturbances  in  premature  infants 
should  be  given  the  utmost  consideration. 

10.  The  method  of  administration  of  food  in  each  case 
varies  with  the  vitality  of  the  infant. 

11.  In  all  cases  of  prematurity,  syphilis  should  be 
thought  of ;  and  in  cases  in  which  there  is  the  slightest 
suspicion,  the  infant  must  not  be  placed  directly  on  the 
breast  of  a  wet-nurse. 


PART  III. 
Artificial  Feeding. 


CHAPTER    I. 

RECENT    PROGRESS    IN    ARTIFICIAL 
FEEDING. 

The  presentation  of  the  subject  of  artificial  feeding 
without  a  review  of  the  progress  and  evolution  which 
our  ideas  on  this  subject  have  undergone  during  the  past 
years  might  easily  mislead  the  student  to  the  belief  that 
the  last  word  in  artificial  feeding  of  infants  has  been 
said.  The  men  who  have  given  this  subject  the  most  con- 
sideration, we  believe,  would  agree  that  much  is  to  be 
hoped  for  in  the  future  in  artificial  feeding. 

It  is  most  difficult  to  present  in  a  concise  manner  the 
best  that  we  have  learned  in  artificial  feeding  so  that  it 
may  be  practically  applied,  because  of  two  very  important 
factors  which  make  for  success:  (1)  a  careful  interpre- 
tation of  the  needs  of  the  individual  infant,  and  (2)  ex- 
perience on  the  part  of  the  feeder  to  meet  those  needs. 

It  remained  for  the  American  school  of  pediatrics  to 
do  the  pioneer  work  in  placing  artificial  feeding  on  a 
scientific  basis. 

Pepper  and  Meigs,  of  Philadelphia,  gave  us  the  first 
rational  method  in  milk  modification.  They  more  espe- 
cially attempted  to  vary  the  percentages  of  casein  in 
cow's  milk,  believing  that  the  excessive  quantity  con- 
tained in  cow's  milk  was  in  great  part  the  cause  of  feed- 

(107) 


108  INFANT   FEEDING. 

ing  difficulties.  This  was  accomplished  by  diluting  the 
milk  and  adding  milk-sugar  and  cream  to  make  up  the 
deficiency  in  energy  value. 

Rotch,  of  Boston,  made  further  advances  in  infant 
feeding  in  that  he  taught  us  that  fat  and  sugar,  as  well 
as  protein,  were  important  factors  in  the  disturbances  of 
the  artificially  fed  infants.  His  work  on  percentage  feed- 
ing, whereby  he  increased  or  decreased  the  various  con- 
stituents of  human  milk  to  meet  definite  clinical  pictures, 
was  probably  the  first  epoch-making  advance  in  infant 
feeding,  and  his  system  of  feeding  has  since  been  known 
as  "the  percentage  method"  of  infant  feeding. 

The  German  school,  of  which  Rubner  and  Heubner 
were  the  chief  advocates,  gave  us  the  so-called  "caloric 
method"  of  feeding,  by  which  they  sought  to  provide  the 
number  of  heat  units  required  by  the  infant,  basing  their 
estimations  on  the  infant's  weight.  Of  this  method  we 
will  have  occasion  to  speak  later.  It  is  sufficient  to  state 
that  we  do  not  now  use  this  as  a  method  of  feeding,  but 
find  a  check  on  the  caloric  contents  of  the  food  of  in- 
estimable value  in  determining  the  value  of  our  mixtures 
in  avoiding  over-  and  under-  feeding.  The  German 
school  have  never  attempted  the  refinements  in  the  per- 
centage composition  of  their  mixtures  as  advocated  by 
the  American  school. 

More  recently  Czerny  and  Finkelstein  have  taught  us 
the  dangers  of  overfeeding  with  whole  milk,  and  also  its 
individual  ingredients,  fat,  sugar,  and  salts,  individually 
and  in  combination.  Their  studies  have,  on  the  whole, 
ignored  the  proteins,  in  all  probability  due  to  the  fact 
that  protein  disturbances  other  than  those  seen  in  infants 
suffering  from  an  idiosyncrasy  to  cow's  milk  are  for  the 
most  part  limited  to   infants   fed  on   raw   cow's   milk, 


PROGRESS    IN    ARTIFICIAL   FEEDING.  109 

while  most  of  the  Continental  clinics  have  for  several 
years  fed  boiled  milk.  Their  studies  and  conclusions  will 
be  more  fully  discussed  under  the  disturbances  of  arti- 
ficially fed  infants. 

During  the  past  few  years  there  has  been  an  increased 
tendency  to  boil  cow's  milk  before  feeding  to  the  infants 
in  American  clinics,  based  on  the  desire  to  render  the 
curd  more  fragile,  and  at  the  same  time  to  destroy  the 
pathogenic  bacterial  content  of  the  milk.  While  this  has 
many  advantages,  it  must  not  be  forgotten  that  it  must 
necessarily  cause  changes,  more  especially  in  the  fer- 
ments, vitamines,  and  salts,  which  are  of  vital  importance 
to  human  economy.  The  ferments  are  believed  to  be  im- 
portant to  the  infant,  and  this  importance  has  been  em- 
phasized especially  since  the  introduction  of  pasteuriza- 
tion and  boiling  of  milk,  for  the  reason  that  a  high  degree 
of  heat  destroys  them. ,  Some  of  the  ferments  are  normal 
constituents  of  milk,  such  as  lipase,  galactase,  lacto- 
kinase,  and  diastase.  The  absence  of  ferments  in  the 
milk  indicates  that  it  has  been  heated.  Hamburger's 
studies  on  the  biologic  differences  in  human  and  cow's 
milk  are  unquestionably  of  vast  importance,  and  though 
there  has  been  a  tendency  in  recent  years  to  neglect  this 
factor  in  infant  feeding,  we  believe  that  it  will  again 
receive  more  important  recognition  in  the  near  future. 
The  changes  caused  in  milk  by  boiling  make  it  necessary 
to  administer  fruit  and  vegetable  juices,  non-dextrinized 
cereals,  and  other  foods,  such  as  codliver  oil,  to  prevent 
the  retarded  development  on  the  part  of  the  infant. 


CHAPTER    II. 
COW'S    MILK. 

No  method  of  artificial  feeding  can  perfectly  replace 
nursing  or  human  milk  feeding.  This  must  be  admitted, 
notwithstanding  the  many  advances  that  have  been  made 
in  infant  feeding  during  recent  years. 

The  best  substitute  for  nursing  is  feeding  with  prop- 
erly modified  milk  of  other  animals,  and  cow's  milk,  for 
practical  reasons,  was  found  to  be  the  one  best  suited  for 
this  purpose. 

There  are  marked  chemical,  physical,  and  biologic  dif- 
ferences between  the  human  milk  and  cow's  milk,  which 
account  for  the  superiority  of  human  milk  over  the  cow's 
milk  in  infant   feeding. 

How  Cow's  Milk  Differs  from  Maternal  Milk.  The 
differences  between  these  two  milks  summarized  in  a 
table  w^hich  follows  are  greater  than  the  table  indicates. 
While  cow's  milk  may  be  modified  to  approximate 
woman's  milk  in  composition,  it  can  never  be  just  the 
same  or  just  as  good  for  infants. 

Cow's  milk  is  more  opaque  than  human  milk,  although 
the  latter  may  contain  a  greater  percentage  of  fat.  This 
is  due  to  the  opacity  of  the  calcium-casein,  which  is  pres- 
ent in  greater  proportion  in  cow's  milk.  Cow's  milk  is 
faintly  acid  or  amphoteric  w^ien  freshly  drawn,  but  ordi- 
narily is  distinctly  acid  in  reaction  when  consumed. 
Human  milk  is  amphoteric  or  alkaline. 

There  is  three  times  as  much  protein  in  cow's  milk  as 
in  human  milk.  The  reason  for  this  is  obvious,  when  we 
recall  that  the  ratio  of  the  growth  of  the  calf  to  that  of 
(110) 


COW'S    MILK.  Ill 

the  infant  is  about  as  2:  1.  Furthermore,  the  protein  in 
cow's  milk  consists  chiefly  of  casein  (3.02  per  cent.)  and 
Httle  lactalbumin  (0.53  per  cent.),  while  human  milk  con- 
tains 0.59  per  cent,  of  casein  and  1.23  per  cent,  lactal- 
bumin. The  sugar  in  the  two  milks  varies  greatly  in 
amount,  but  not  in  kind.  Cow's  milk  contains  almost 
four  times  the  amount  of  inorganic  salts  compared  to 
woman's  milk.  Of  more  importance,  the  salts  in  cow's 
milk  consist  mainly  of  potassium  and  sodium  bases. 
These  differences  have  an  important  bearing  upon  in- 
fant's metabolism.  There  is  no  great  difference  in  the 
average  amount  of  fat  in  the  two  milks;  however,  both 
in  human  milk  and  in  cow's  milk  the  fat  is  the  most 
variable  constituent. 

The  curd  from  cow's  milk  is  usually  tougher  and  in 
larger  masses  than  in  human  milk.  There  are  also  dif- 
ferences in  antibodies,  ferments,  etc. 

Cow's  Milk  Human  Milk 

Amphoteric  or  acid   .  Reaction    Amphoteric     or     alk- 
aline 

1.029  to  1.034 Sp.  gr 1.010  to  1.040 

3.5  per  cent Proteins  1.5  to  2.0  per  cent. 

2.66  per  cent Caseinogen    0.5  to  0.75  per  cent. 

0.53  per  cent Lactalbumin    1.23  per  cent. 

Clots  in  large  lumpy 

curds    Effect  of  rennin  .....Clots  in  fine  curds 

4.0  per  cent Fat    3.5  to  4.0  per  cent. 

4.5  per  cent Lactose    6.0  to  7.0  per  cent. 

0.75  per  cent Salts    0.2  per  cent. 

13  to  14  per  cent.  ...Total  solids 12  to  13  per  cent. 

86  to  87  per  cent.  . . .  Water   86  to  88  per  cent. 

Never  sterile    Bacterial  contents    ...Practically  sterile 

Biedert,  whose  theory  found  many  followers  at  one 
time,  believed  that  casein  of  the  cow's  milk  was  the  dis- 
turbing factor  in  artificial  feeding. 


112  INFANT   FEEDING. 

The  large,  tough  curds  forming  from  the  casein  of  raw 
cow's  milk  differ  considerably  from  the  fine  flocculent 
curds  of  the  human  milk  casein.  Steps  have  been  taken 
to  make  the  cow's  milk  curd  resemble  the  human  milk 
curd  in  its  physical  properties,  such  as  boiling  the  milk, 
citration  and  addition  of  cereal  waters,  and  it  was  found 
that  this  modification  considerably  improved  the  results 
of  artificial  feeding. 

The  differences  in  the  fat  contents  of  the  two  milks 
have  less  frequently  been  drawn  upon  for  explanation  of 
frequent  nutritional  disturbances  on  artificial  feeding, 
although  it  has  positively  been  established  that  fat  plays 
an  important  part  in  the  nutritional  disturbances  of  the 
artificially  fed  infant.  The  butter  prepared  from  cow's 
milk  contains  10  per  cent,  of  volatile  acids,  while  that 
prepared  from  the  human  milk  only  1.5  per  cent.  And 
especially  the  irritant  butyric  acid  glycerid,  which  is  con- 
tained in  6  per  cent,  in  butter  prepared  from  cow's  milk, 
is  contained  only  in  traces  in  human  milk.  The  fat  drops 
of  cow's  milk  are  also  on  the  whole  much  larger  than 
those  of  human  milk. 

Lactose  is  the  principal  sugar  in  both  cow's  and  human 
milk,  average  human  milk  containing  6  to  7  per  cent., 
and  cow's  milk  4  to  5  per  cent.  This  increased  sugar 
contents  of  the  human  milk,  with  its  fermentation,  ac- 
counts for  the  laxative  effect  of  breast  milk  feeding  when 
the  milk  is  abundant. 

L.  F.  Meyer  has  experimentally  shown  that  salts  of  the 
cow's  milk,  which  vary  both  quantitatively  and  qualita- 
tively from  those  of  human  milk,  have  unfavorable  in- 
fluence on  children  with  nutritional  disturbances.  While 
we  cannot  from  these  experiments  conclude  that  the  same 
holds  true  for  normal,  healthy  children,  yet  we  have  to 


COW'S    MILK.  113 

admit  that  the  salt  contents  of  the  two  milks  are  of  great 
importance  in  artificial  feeding. 

Escherich  and  Hamburger  were  of  the  opinion  that 
human  milk  contained  ferments  which  favorably  influ- 
enced the  processes  of  metabolism.  Salge  found  that 
tetanus  and  diphtheria  antitoxins  could  be  utilized  by  the 
infant  only  when  fed  in  human  milk,  while  when  con- 
tained in  the  milk  of  other  species  they  did  not  get  into 
the  body  fluids  of  the  infant.  But  whether  these  biologic 
differences  are  of  great  importance  to  the  infant  remains 
to  be  proven. 

Although  it  seems  probable,  yet  it  has  not  been  demon- 
strated that  cowl's  milk  feeding  taxes  the  digestive  func- 
tions of  the  infant's  organism  more  than  human  milk 
feeding. 

Of  great  importance  is  the  bacterial  contents  of  the 
milk,  the  human  milk  being  either  sterile  or  of  low  bac- 
terial contents,  while  cow's  milk  is  never  sterile,  and  not 
infrequently  its  bacterial  contents  is  very  high.  Steril- 
ized, pasteurized,  and  certified  milk  were  the  practical  re- 
sults of  the  efforts  to  obtain  germ-free  milk  for  infant 
feeding. 

The  milk  for  infant  feeding  must  come  from  healthy 
cow^s,  must  be  obtained  in  clean  manner  into  clean  re- 
ceptacles, must  be  cooled  very  soon  after  milking  in  order 
to  keep  down  the  bacterial  content,  and  kept  cool  after- 
wards. It  must  be  delivered  to  the  consumer  as  soon 
as  possible  in  such  a  way  as  to  prevent  any  contamina- 
tion, and  must  be  handled  in  the  home,  cleanly,  in  sterile 
receptacles,  and  at  all  times  be  kept  cool. 

The  cow  from  which  the  milk  is  obtained  must  be 
entirely  healthy,  and  be  especially  free  from  tuberculosis 
and  glanders,  tuberculin  and  mallein  test  being  advisable 


114  IXFAXT   FEEDING. 

as  a  routine,  besides  general  examination  of  the  cow. 
The  cows  must  be  kept  clean,  in  a  clean  stable,  which 
is  well  ventilated  and  drained.  Xo  dust,  manure,  or  fod- 
der, except  that  used  for  immediate  feeding,  should  be 
kept  in  the  stable.  The  cows  should  be  kept  clean,  but 
even  then  they  should  be  cleaned  again  immediately  be- 
fore milking. 

The  milking  must  be  done  in  a  clean  way  and  milk 
kept  clean  afterwards,  in  order  that  the  bacterial  count 
may  be  as  low  as  possible.  Dry  feeding  of  the  cows  is 
preferable,  since  on  this  feeding  the  feces  is  less  liquid, 
and  cows  can  be  kept  clean  with  less  difficulty.  The 
milkers  should  be  free  from  any  communicable  disease, 
and  be  of  clean  habits.  The  udders  of  the  cows  and  the 
hands  of  the  milker  should  be  scrubbed  with  warm 
water  and ,  soap  immediately  before  milking,  and  anti- 
septic solution  may  be  applied  afterwards.  Milking 
should  be  done  into  covered  cans,  and  m.ilk  made  to  pass 
through  a  filter  first.  The  cans  should  be  always  cleaned 
immediately  after  the  milk  is  poured  out,  first  with  cold 
and  then  with  hot  water,  and  also  rinsed  out  with  hot 
water  before  milking.  The  first  few  ounces  of  milk 
should  be  discarded,  since  this  milk  contains  large 
amoimts  of  bacteria  that  are  washed  out  from  the  ex- 
cretory ducts. 

Cooling  the  milk  after  it  is  obtained  is  a  very  impor- 
tant step  in  the  production  of  clean  milk.  The  milk  hav- 
ing been  obtained  with  the  above-described  precautions, 
with  as  few  bacteria  as  possible,  should  be  cooled  at 
once  in  order  to  prevent  growth  and  multiplication  of 
the  bacteria  that  have  entered  the  milk  in  spite  of  all  the 
precautions.  This  is  accomplished  by  special  cooling  ap- 
paratuses, or  simply  by  pouring  the  milk  into  sterilized 


COW'S   MILK.  115 

bottles,  closing  with  sterilized  cap,  and  putting  on  ice. 
The  milk  in  bottles  should  be  kept  iced  until  it  reaches 
the  consumer,  which  should  not  take  longer  than  twenty- 
four  hours. 

In  the  home  precautions  should  be  taken  to  prevent 
additional  contamination,  and  to  keep  the  milk  iced  to 
prevent  further  growth  of  bacteria,  until  everything 
necessary  is  ready  for  making  the  proper  mixture  for  in- 
fant feeding.  Many  good  milks  are  spoiled  on  the  door- 
step of  the  home  between  the  hour  of  delivery  and  plac- 
ing the  milk  in  the  ice-box.  All  the  utensils  and  vessels 
used  for  preparing  the  mixture  must  be  perfectly  clean 
and  sterilized  by  boiling.  As  soon  as  the  mixture  is  made 
it  should  be  put  into  the  ice-box  again  and  kept  there, 
portions  being  taken  during  the  day  for  individual  feed- 
ings, and  warmed  separately  just  before  feeding. 

Certified  Milk.  The  term  "certified  milk"  was  coined 
by  Dr.  Henry  L.  Coit,  of  Newark,  N.  J.,  who  in  1892, 
needing  good  milk  for  his  own  baby,  formulated  a  plan 
for  the  production  of  clean,  fresh,  pure  milk  under  the 
auspices  of  a  medical  milk  commission.  The  term  "cer- 
tified m.ilk,"  then,  is  the  milk  of  the  highest  quality,  of 
uniform  composition,  obtained  by  cleanly  methods  from 
healthy  cows,  under  the  special  supervision  of  a  medical 
milk  commission. 

The  use  of  the  term  "certified  milk"  should  be  limited 
to  milk  produced  in  accordance  with  the  requirements  of 
the  American  Association  of  Medical  Milk  Commission- 
ers. The  first  requisite  in  the  production  of  certified 
milk  is  to  enlist  the  co-operation  of  a,  trustworthy  dairy- 
man who  is  willing  to  enter  into  a  contract  with  the 
medical  milk  commission.  In  accordance  with  the  terms 
of  this  contract,  .the  dairyman  binds  himself  to  comply 


116  INFANT   FEEDING. 

with  the  specifications  set  forth,  and  in  return  his  milk 
is  certified. 

The  dairies  are  subjected  to  periodic  inspections,  and 
the  milk  to  frequent  analyses.  The  cows  producing  cer- 
tified milk  must  be  free  from  tuberculosis,  as  shown  by 
the  tuberculin  test  and  physical  examination  by  a  quali- 
fied veterinarian,  and  from  all  other  communicable  dis- 
ease, and  from  all  diseases  and  conditions  whatsoever 
likely  to  deteriorate  the  milk.  They  must  be  housed  in 
clean,  properly  ventilated  stables  of  sanitary  construc- 
tion, and  must  be  kept  clean  and  properly  fed  and  cared 
for.  All  persons  who  come  in  contact  with  the  milk  must 
exercise  scrupulous  cleanliness,  and  must  not  harbor  the 
germs  of  typhoid,  tuberculosis,  diphtheria,  or  other  in- 
fections liable  to  be  conveyed  by  the  milk.  Milk  must  be 
drawn  under  all  precautions  necessary  to  avoid  contam- 
ination, and  must  be  immediately  cooled,  placed  in  steril- 
ized bottles,  and  kept  at  a  temperature  not  exceeding  50° 
F.,  until  delivered  to  the  consumer.  Pure  water,  as  de- 
termined by  chemical  and  bacteriological  examination,  is 
to  be  provided  for  use  throughout  the  dairy  farm  and  the 
dairy.  Certified  milk  should  not  contain  more  than  10,- 
000  bacteria  per  cubic  centimeter,  and  should  not  be  more 
than  thirty-six  hours  old  when  delivered. 

Inspected  Milk.  This  term  should  be  limited  to 
clean,  fresh  milk  from  healthy  cows,  as  determined  by 
the  tuberculin  test  and  physical  examination  by  a  quali- 
fied veterinarian.  The  cows  are  to  be  fed,  watered, 
housed,  and  milked  under  good  conditions,  but  not  neces- 
sarily equal  to  those  prescribed  in  the  production  of  cer- 
tified milk.  Scrupulous  cleanliness  must  be  exercised  and 
particular  care  be  taken  that  persons  having  communi- 
cable diseases  do  not  come  into  contact  with  the  milk. 


COW'S    MILK.  117 

This  milk  must  be  delivered  in  sterilized  containers,  and 
kept  at  a  temperature  not  exceeding  50°  F.  until  it 
reaches  the  consumer.  There  should  be  not  more  than 
100,000  bacteria  per  cubic  centimeter  of  inspected  milk. 
This  milk  should  be  pasteurized. 

Market  Milk.  All  milk  that  is  not  certified  or  in- 
spected in  accordance  with  the  above  definitions,  and  all 
milk  that  is  of  unknown  origin,  is  classed  as  "market 
milk,"  and  should  be  pasteurized. 

Frozen  Miik.  In  our  own  experienc*e  we  have  found 
that  many  infants  were  made  ill  by  feeding  of  raw  frozen 
milk  which  has  been  rapidly  thawed,  and  allowed  to 
stand  in  a  warm  room,  with  resulting  vomiting,  and  not 
infrequently  diarrhea.  These  symptoms  are  obviated 
when  the  milk  is  boiled.  Pennington  and  her  collabora- 
tors found  very  definite  changes  in  milk  after  freezing. 
They  found  that  when  the  milk  is  held  at  a  temperature 
of  0°  C.  there  is  proteolysis  of  the  casein,  which  is  pri- 
marily of  bacterial  origin,  and  proteolysis  of  the  lactal- 
bumin,  due  primarily  to  the  native  enzymes  of  the  milk. 
The  action  of  these  two  agents  together  is  more  rapid 
than  that  of  either  alone.  The  bacteria  and  enzymes  may 
break  down  the  true  protein  and  carry  the  breaking  down 
through  to  peptones,  even  to  amino-acids.  There  is  a 
fermentation  of  lactose  with  the  formation  of  lactic  acid, 
which  is  largely,  if  not  exclusively,  due  to  bacterial 
action.  The  fat,  so  far  as  can  be  determined,  is  not 
affected  except  by  the  action  of  bacteria. 

Mixed  Milk  Versus  Milk  of  One  Cov^\  It  is  far  bet- 
ter, other  things  being  equal,  to  use  the  mixed  milk  of  a 
herd  in  preparing  a  baby's  food  than  the  milk  of  one 
cow,  because  if  the  milk  comes  from  one  cow,  and  the 
cow  is  ill  in  any  way,  the  baby  is  almost  certain  to  be  dis- 


118  INFANT   FEEDING. 

ttirbed,  whereas  if  one  or  two  cows  in  a  herd  are  ill,  the 
milk  from  these  cows  will  be  so  diluted  that  the  baby  will 
probably  not  notice  it.  On  the  other  hand,  it  is,  or  should 
be,  self-evident  that  the  milk  of  a  healthy  cow  properly 
fed  and  properly  cared  for,  taken  in  the  proper  way,  and 
kept  under  proper  conditions,  is  better  than  the  mixed 
milk  of  a  herd  which  is  improperly  fed,  and  whose  milk 
is  not  carefully  obtained  or  carefully  taken  care  of. 

Boiling,  Sterilization,  and  Pasteurization.  Before 
entering  into  a  discussion  of  this  subject,  it  is  only  fair 
to  state  that  the  general  teaching  in  America  of  feeding 
with  raw  milk  has  led  to  the  production  of  safe,  clean 
certified  milk  in  the  large  communities  where  so  many 
fatalities  were  experienced  through  the  feeding  of  un- 
clean milk.  Any  methods  of  handling  milk  which  will  in 
the  least  interfere  with  the  proper  production  of  clean 
milk,  and  lead  to  the  feeling  that  unclean  milk  can  be 
made  safe  for  infant  feeding  by  the  application  of  heat  or 
other  methods,  would  be  a  backward  step  in  infant  feed- 
ing, and  would  necessarily  cause  dire  results.  While  the 
European  countries,  like  Germany  and  France,  have  ad- 
vocated feeding  boiled  milk  for  many  years  without  fear 
of  bad  nutritional  disturbances  due  to  the  changes  in  the 
milk,  in  America  feeding  with  raw  milk  has  until  re- 
cently been  favored.  Increased  experience  with  boiled 
milk,  especially  by  those  who  have  long  used  raw  milk, 
leads  to  the  growing  conviction  that  boiled  milk  is  more 
easily  digested  than  raw  milk  by  dyspeptic  infants,  ana 
hence  by  the  well  infants. 

\Miile  we  do  not  believe  that  feeding  with  boiled  milk 
should  be  advised  as  a  general  measure,  when  it  is  pos- 
sible to  obtain  a  good  certified  milk,  and  when  the  latter 
is  to  be  placed  in  the  bands  of  mothers  and  nurses  who 


cows    MILK.  119 

can  be  depended  upon  to  keep  the  milk  clean  and  whole- 
some through  proper  icing  and  handling,  we  do  believe 
that  when  these  requirements  cannot  be  met,  that  it  is 
safer  even  in  well  babies  to  feed  a  thoroughly  sterilized 
milk,  and  that  this  can  be  done  without  danger  of  de- 
velopment of  scurvy  and  rickets,  when  these  feedings  are 
accompanied  by  the  administration  of  fruit  juices,  vege- 
table soups,  and  purees  and  codliver  oil. 

Brennemann  suggests  that  we  must  answer  the  follow- 
ing questions  before  deciding  as  to  whether  we  should 
feed  raw,  pasteurized,  or  boiled  milk : 

(1)  Does    raw   milk   offer   advantages   over   boiled 

milk? 

(2)  Does   boiled   milk   offer   advantages    over    raw 

milk  ? 

(3)  Does  pasteurization  solve  the  problem? 

(4)  Does  certified  milk  solve  the  problem? 

In  answer  to  the  first  question  we  must  decide  whether 
the  changes  caused  in  milk  by  boiling,  such  as  partial 
coagulation  of  lacto-albumin,  caramelization  of  some  of 
the  milk-sugar,  its  action  on  casein,  inhibiting  coagula- 
tion with  rennin,  etc.,  lessen  the  nutritive  value  of  cow's 
milk  as  an  infant  food.  We  believe  that  the  sentiment  of 
American,  German,  and  French  clinics,  in  which  boiled 
milk  has  been  used  for  a  long  period  of  time,  is  to  the 
effect  that  the  nutritive  value  of  boiled  milk,  with  its  les- 
ser dangers,  are  on  the  whole  in  favor  of  boiled  milk. 

Constipation  has  been  suggested  as  an  argument 
against  boiling  milk.  We  believe  that  constipation  in  the 
bottle-fed  baby  is  one  of  the  safest  earmarks  of  the  well- 
being  of  the  infant,  and  that  only  that  constipation  which 
is  due  to  excessive  feeding  of  fat,  and  which  will  be 
described  under  Disturbed  Metabolic  Balance,  is  an  ex- 


120  INFANT   FEEDING. 

ception  to  this  statement.  While  with  raw  milk  digestive 
disturbances  are  frequently  seen  before  sufficient  milk  is 
given  to  properly  nourish  the  infant,  this  is  far  less  com- 
mon with  boiled  milk;  in  fact,  it  has  not  infrequently 
been  our  experience  that  we  have  overfed  with  boiled 
milk,  because  the  infant  handles  it  with  so  much  better 
advantage.  In  digestive  disturbances,  with  loose  stools, 
it  is  digested  to  much  better  advantage  than  raw  milk, 
which  frequently  results  in  formation  of  hard  casein 
curds  as  well  as  fat  curds.  The  assertion  that  feeding 
with  boiled  milk  results  in  anemia,  underdevelopment  and 
rickets,  we  believe,  is  not  well  founded,  and  these  condi- 
tions, when  present,  are  due  to  other  causes.  Scurvy  de- 
veloping during  the  course  of  feeding  with  boiled  milk 
has  never  been  seen  in  our  experience,  except  when  some 
of  the  proprietary  infant  foods  have  been  fed  in  con- 
junction with  boiled  milk.  That  under  certain  conditions 
scurvy  should  develop  in  presence  of  long-continued  feed- 
ing with  boiled  milk  alone,  is  not  to  be  denied.  The  dan- 
gers, however,  are  very  remote,  as  testified  to  by  the 
German  and  French  clinicians.  When  such  dangers  are 
feared,  they  can  easily  be  overcome,  as  previously  sug- 
gested, by  the  feeding  of  fresh  fruit  juices  and  vegetable 
preparations  together  with  the  milk  diet. 

Does  boiled  milk  offer  advantages  over  raw  milk? 
Boiled  milk  when  properly  handled  is  relatively  free 
from  pathogenic  micro-organisms,  and  if  the  milk,  which 
has  been  boiled,  was  clean  milk,  also  from  their  toxic 
products.  In  raw  milk  we  have  a  tendency  even  in  clean 
milk  to  bacterial  growth  which  causes  souring,  and  which 
is  not  pathological,  while  when  the  lactic  acid  organisms 
are  destroyed  by  boiling,  in  proper  handling  of  boiled 
milk  it  will  result  in  decomposition  with  its  attendant 


COW'S    MILK.  121 

dangers.  Boiling  in  the  home  has  the  great  advantage 
over  commercial  pasteurization  and  boiling  in  that,  if 
the  milk  is  raw  and  spoiled  before  it  reaches  the  home, 
this  can  readily  be  detected  by  the  housewife.  While 
we  know  that  certain  pathogenic  organisms  may  de- 
velop in  the  milk  without  giving  evidence  of  their  pres- 
ence, and  cause  formation  of  toxic  bodies  which  are  not 
removed  by  boiling  in  the  home,  the  latter  process  still 
offers  every  advantage  over  commercial  pasteurization. 
Boiling  milk  in  the  home  will  most  certainly  remove  the 
dangers  from  infection  with  tuberculosis,  scarlet  fever, 
streptococcus  sore  throat,  typhoid  fever,  dysentery,  and 
many  other  milk-borne  diseases.  The  advantages  of 
boiled  milk  in  the  presence  of  indigestion  and  diarrhea 
have  already  been  mentioned.  The  small,  flocculent  curd 
of  the  boiled  milk  is  also  rapidly  and  more  easily  digested 
than  the  large,  tough  casein  curds  of  the  raw  milk.  The 
hard  bean-like  protein  curds  are  never  seen  in  stools  of 
the  infant  fed  on  milk  which  has  been  thoroughly  boiled, 
although  we  have  occasionally  seen  them  in  overfeeding 
with  cow's  milk  which  has  been  heated  by  the  double 
boiler  process.  These  latter  cases,  however,  are  ex- 
ceptions. 

Larger  amounts  and  more  concentrated  mixtures  of 
boiled  milk  can  be  fed  than  in  feeding  with  raw  milk. 
This  is  a  distinct  advantage  in  the  beginning  of  the  feed- 
ing of  atrophic  infants.  This  latter  advantage  is  not  to 
be  overlooked.  While  the  large  percentage  of  healthy 
babies  will  apparently  digest  equally  well  raw  and  boiled 
milk  within  therapeutic  limits,  it  will  be  found  that  most 
authors  who  do  not  resort  to  heating  milk  will,  at  least  in 
some  other  way,  modify  the  curd  of  raw  cow's  milk, 
either  by  simple  dilution,  by  the  use  of  cereal  waters  or 


122  INFANT    FEEDING. 

an  alkaline,  such  as  lime  water  or  sodium  citrate.  We 
agree  with  Brennemann  in  his  statements  that  boiling 
commends  itself  as  an  excellent  casein  modifier,  and  that 
it  effectually  disposes  of  the  majority  of  bacteriological 
problems  when  the  milk  is  properly  handled  after  boiling. 

Pasteurization  zrrsiis  Boiling.  Pasteurization  was 
first  recommended  because  of  the  belief  that  boiled  milk 
has  scorbutic  properties,  which  could  not  be  laid  at  the 
door  of  pasteurized  milk.  The  question  of  the  relation- 
ship between  boiled  milk  and  scurvy  has  already  been 
touched  upon.  Pasteurization  in  the  home  is  not  a  very 
satisfactory  process.  Commercial  pasteurization,  even 
though  properly  carried  out,  is  too  distant  from  the 
probable  time  of  consumption  of  the  food  to  be  a  safe 
measure,  unless  the  milk  is  properly  handled  after  pas- 
teurization. The  best  argument  presented  by  the  advo- 
cates of  pasteurization  is  that  the  milk  is  essentially  a 
raw  milk  in  so  far  as 'its  physiological  properties  are 
concerned. 

Certified  Milk  I'ersus  Boiling.  Clean  certified  milk, 
properly  handled,  both  before  and  after  it  reaches  the 
home,  and  where  the  cost  is  not  prohibitive,  -when  well 
digested  by  the  individual  infant,  still  remains  the  ideal 
food  for  artificial  feeding.  When  these  requirements 
cannot  be  met,  boiling  in  the  home  is  the  best  method 
for  preparation  of  milk  for  the  infant. 

Various  Methods  of  Boiling  Milk.  In  our  own  work 
we  have  resorted  in  most  cases  to  the  heating  of  the 
milk  in  a  double  boiler.  This  has  several  advantages  in 
that  the  milk  is  heated  in  a  closed  vessel,  and  has  then  a 
less  pronounced  flavor  than  when  heated  in  open  ves- 
sels, and  causes  but  little  pellicle  formation,  unless  we 
have  a  very  thin  column  of  milk.    To  overcome  this  lat^ 


COW'S    MILK.  123 

ter,  we  therefore  recommend  the  smallest  double  boiler 
which  can  be  obtained,  and  which  will  at  the  same  time 
hold  all  of  the  milk  which  is  to  be  prepared.  The  milk 
mixture  is  put  in  the  inner  receptacle,  cold,  and  the  water 
in  the  outer  vessel  also  cold.  The  double  boiler  is  then 
placed  on  the  stove,  and  allowed  to  remain  until  the 
water  in  the  outer  vessel  boils  for  six  to  eight  minutes. 
While  the  milk  heated  in  this  manner  forms  a  very  much 
finer  and  softer  curd  than  that  of  raw  milk,  it  is  not  as 
fine  as  that  of  milk  boiled  directly  over  the  flame.  How- 
ever, in  most  cases,  it  answers  all  purposes,  and  has 
the  advantages  above  enumerated.  In  the  presence  of 
gastric  and  intestinal  indigestion  and  allied  conditions, 
the  finer  curd  of  the  milk  boiled  directly  over  the  flame 
may  be  more  suitable ;  and  in  exceptional  cases,  when 
boiling  over  the  direct  flame  for  three  to  five  minutes  does 
not  give  the  desired  result,  milk  boiled  for  30  to  45 
minutes  over  the  direct  flame  will  offer  further  advan- 
tages, and  this  method  is  worthy  of  trial  for  temporary 
use. 


CHAPTER    III. 

ADAPTATION    OF    MILK    FOR    INFANT 
FEEDING. 

From  the  foregoing  it  may  be  seen  that  there  is  no  per- 
fect substitute  for  human  milk  in  the  feeding  of  the  in- 
fant, and  therefore  every  effort  should  be  made  to  assist 
the  mother  in  the  nursing  of  her  infant. 

Since  all  the  attempts  made  to  feed  an  infant  on  the 
food  not  primarily  intended  for  this  purpose  are  at- 
tempts at  milk  adaptation,  we  necessarily  know  that  no 
single  method  can  possibly  meet  the  needs  of  all  infants. 

And  therefore  it  must  be  our  object,  first,  to  formulate 
our  rules  so  as  to  make  them  safe  and  adaptable  to  the 
feeding  of  the  majority  of  well  babies,  leaving  the  dis- 
cussion of  exceptional  and  sick  babies  for  further  study. 
It  must  necessarily  go  without  saying  that  the  food 
recommended  will  be  excessive  for  some  and  inadequate 
for  others.  Every  organism  has  its  individuality  and  its 
fixation  coefficient,  and  every  infant  makes  a  different  use 
of  the  food  administered  to  it.  All  infants  cannot,  there- 
fore, be  treated  according  to  the  same  rule. 

While  many  excellent  results  have  been  reported  with 
the  various  methods  described  for  artificial  feeding  of  in- 
fants, and  some  attempt  has  been  made  to  place  feeding 
on  a  scientific  basis,  we  believe  that  we  must  concede 
that  the  methods  are  all  more  or  less  empirical,  and  the 
result  will  be  in  considerable  degree  dependent  upon  the 
wide  range  of  food  tolerance  of  the  healthy  infant.  The 
successful  physician  must  depend  on  the  clinical  ob- 
servation of  the  individual  infant  for  the  success  of  the 
(124) 


MILK   FOR   INFANT    FEEDING.  125 

method  of  feeding  which  he  is  using.  Every  formula 
with  which  we  start  feeding  should  be  looked  upon  in 
the  light  of  an  experiment,  and  the  reaction  of  the  infant 
to  this  feeding  should  be  carefully  studied. 

If  these  principles  are  borne  in  mind,  many  an  ob- 
stacle to  successful  infant  feeding  will  be  avoided. 

We  believe  that  the  attempts  toward  ultra  refinement 
of  the  infant's  diet  has  led  to  considerable  confusion,  be- 
cause of  the  different  conclusions  of  the  various  schools 
undertaking  the  work.  Eventually,  however,  infant  feed- 
ing will  be  placed  on  a  thoroughly  scientific  basis.  This, 
however,  does  not  answer  the  pressing  needs  of  to-day, 
which  call  for  a  safe  and  practical  solution  of  the  feed- 
ing problem  for  the  feeding  of  the  everyday  baby  in 
everyday  life.  The  baby  is  so  commonly  receiving  its 
feeding  advice  from  food  manufacturers ;  and  if  feeding 
on  one  preparation  is  not  successful,  there  is  a  rapid 
transition  from  one  proprietary  baby  food  to  another, 
with  untold  detriment  to  the  infant.  In  advancing  the 
rules  for  feeding  the  normal  healthy  infant,  with  fur- 
ther suggestions  for  the  underfed,  on  simple  milk  mix- 
tures zvith  carbohydrates  added,  we  desire  to  state  that 
in  our  clinical  experience  we  have  found  them  safe  for 
the  baby  and  practical  for  the  physician,  which  latter  is 
neither  to  be  overlooked  nor  taken  lightly. 

We  claim  nothing  original  for  these  feeding  sugges- 
tions, as  they  represent  the  more  common  practice  of  the 
Continent,  and  America  as  well.  We  have,  however, 
formulated  the  rules  which  govern  the  application  of 
simple  milk  mixtures,  with  carbohydrates  added,  in  such 
a  way  that  their  application  becomes  more  practical. 
Kjtiowing  that  the  feeding  advice  which  we  are  to  receive 
and  advise  is  founded  on  clinical  experience,  and  that 


126  INFANT   FEEDING. 

similarly  good  clinical  results  in  feeding  have  been  ob- 
tained by  others  by  various  methods  of  feeding,  we  be- 
lieve it  advisable  to  briefly  review  the  more  popular 
methods  of  infant  feeding  as  practised  today. 

1.  Undiluted  Whole  Milk.  While  undiluted  milk 
has  been  used  with  varying  degrees  of  success  by  some 
German  and  French  pediatricians  (of  the  latter  Budin 
being  the  foremost  advocate),  it  may  be  generally  stated 
that,  on  the  whole,  it  is  not  well  borne  before  the  fourth 
month  of  life.  If  whole  boiled  milk  is  used  in  the  feed- 
ing of  the  very  young  infant,  the  size  of  the  individual 
meal  must  be  greatly  restricted  over  that  as  recommended 
for  diluted  mixtures,  so  that  it  will  not  exceed  the  caloric 
requirements  of  the  individual.  Budin  recommended 
that  all  whole  milk  fed  to  an  infant  should  first  be  boiled, 
which  causes  the  protein  to  be  precipitated  in  the  infant's 
stomach  in  the  form  of  a  fine  curd.  This  can  be  fur- 
ther facilitated  by  the  addition  of  pegnin  or  chymogen, 
which  causes  the  formation  of  the  fine  curds  before  it  is 
fed  to  the  infant,  with  no  recoagulation  in  the  stomach.* 
Alkalinizing  milk  by  the  addition  of  sodium  bicarbonate 
also  results  in  the  formation  of  fine  curds.  In  some 
forms  of  vomiting,  small  quantities  of  a  concentrated 
food  will  frequently  be  found  of  considerable  value.  As 
a  routine  measure  of  feeding,  whole  milk  cannot  be 
recommended. 

2.  The  Percentage  Method  or  System  of  Feeding. 

This  is  frequently  spoken  of  as  the  xAmerican  method,  or 
Rotch's  method,  because  of  the  fact  that  Rotch,  of  Bos- 
ton, did  much  to  popularize  and  systematize  this  method 
of    feeding.      Not  only   did   he   work   out   a    system   of 


*  Brennemann,  Archives  of  Pediatrics,  1917,  34,  81. 


MILK   FOR    INFANT    FEEDING.  127 

formulae  adapted  to  infants  of  varying  ages  and  develop- 
ment, but  he  also  was  the  means  of  establishing  the  first 
so-called  public  milk  laboratory.  The  chief  objections 
to  this  method,  as  originally  described  by  Rotch,  were 
its  lack  of  flexibility  and  the  difficulty  of  remembering  the 
various  formulae  and  their  preparation.  The  followers  of 
the  Rotch  school  state  that  the  percentage  feeding,  so- 
called,  is  not  a  method  of  feeding,  but  merely  a  method 
of  calculation,  and  a  means  of  obtaining  relative  accuracy 
in  the  preparation  of  infants'  foods.  They  have  sim- 
plified the  method  as  originally  applied,  lengthened  the 
feeding  intervals,  and,  while  still  retaining  some  of  the 
original  ideas,  have  made  the  method  far  more  practical. 

3.  Top  Milk  Feeding.  In  this  method  a  definite 
number  of  ounces  of  the  upper  part  of  the  milk,  which 
has  stood  for  a  number  of  hours,  is  used  as  the  basis  for 
preparing  the  mixture  to  be  fed. 

To  successfully  carry  out  top  milk  feeding,  the  per- 
centages of  fat  at  various  levels  in  32  ounces  (quart)  of 
milk  containing  4  per  cent,  of  fat,  and  which  has  stood 
for  six  hours  or  longer,  must  be  known: 

Upper  16  oz.  has  7  per  cent.  fat. 
20    "      "     6     " 

a  -yA       a        a       r       a  n  a 

(1)  This  method  endeavors  to  provide  ample  caloric 
values.  In  this  respect  the  method  may  be  regarded  as 
successful.  (2)  There  is  the  idea  that  casein  is  not 
very  digestible,  and  that  it  is  advantageous  to  feed  casein 
in  small  quantities,  making  up  the  shortage  in  energy 
value  of  the  mixture  with  fat.  In  the  light  of  our  pres- 
ent knowledge,  however,  we  know  that  the  casein  of 
boiled  or  alkalinized  milk,  or  when  mechanically  divided 


128  INFANT   FEEDING. 

by  the  addition  of  cereals,  is  easily  digested.  (3)  The 
attempt  to  produce  a  formula  with  the  percentage  of  fat 
in  the  same  proportion  as  is  found  in  human  milk,  as 
well  as  larger  amounts,  which,  however,  frequently  leads 
to  fat  indigestion,  because  of  the  greater  difficulty  experi- 
enced by  many  infants  in  handling  large  quantities  of 
cow's  milk  fat.  (4)  The  importance  of  the  sugar  and 
salt  content  of  the  mixture  is  underestimated. 

This  method  of  feeding,  nevertheless,  has  many  ad- 
vocates, and  we  would  advise  that  the  above  shortcom- 
ings of  the  method  as  originally  described  be  given  full 
consideration  by  those  adopting  this  method  of  feeding. 


CHAPTER   IV. 

MILK   DILUTIONS   WITH    THE   ADDITION 
OF   CARBOHYDRATES. 

It  has  been  our  experience  that  about  90  per  cent,  of 
the  infants  that  come  under  our  observation  for  artificial 
feeding  will  tolerate  a  wide  range  of  quantitative  values 
in  the  components  of  the  milk,  i.e.,  fats,  proteins,  carbo- 
hydrates, and  salts.  And  the  simpler  the  first  formula 
on  which  the  baby  is  started,  the  easier  we  find  it  to 
meet  its  later  needs  for  growth  and  development,  by  in- 
creasing or  decreasing  the  individual  elements  in  the  diet. 
The  first  step  of  this  method  consists  in  the  dilution  of 
whole  milk  with  water,  thereby  reducing  all  the  ingredi- 
ents of  the  milk.  When  we  compare  such  a  dilution  with 
human  milk  we  find  that  when  protein  approximates  that 
contained  in  breast  milk,  the  fat  is  considerably  reduced 
below  that  contained  in  the  latter.  This  in  practical  feed- 
ing we  find  to  be  an  advantage  rather  than  a  disadvan- 
tage, and  if  there  be  an  indication  for  increasing  the  fat 
content  of  the  formula  this  is  easily  accomplished  by  the 
addition  of  cream,  or  top  milk,  which  is,  however,  usu- 
ally not  necessary,  as  the  deficiency  in  fat  can  usually  be 
successfully  compensated  by  adding  sugar  and  starch 
to  the  formula.  As  a  result  of  dilution,  the  salts,  which 
are  about  three  times  as  great  in  quantity  in  cow's  milk, 
are  reduced  to  more  nearly  the  amounts  contained  in 
breast  milk.  We  must,  however,  remember  that  there  are 
still  great  qualitative  differences  in  the  salt  content  of 
the  cow's  milk  dilution  and  human  milk. 

9  (129) 


130  INFANT   FEEDING. 

In  K2O       NaO       CaO      MgO     F2O3     P0O5       CI 

Human  milk  .  30.1       137     13.5       1.7      0.17     12.7    21.8  %  in  100 

parts  ash 
Cow's  milk  . .  22.14    15.9    20.05    2.63    0.04    24.7    21.27%  in  100 

parts  ash 

Feeding  should  primarily  be  formulated  to  promote 
normal  growth  and  development,  to  supply  energy  for  the 
body  functions,  to  prevent  disease;  and,  although  of  no 
lesser  importance,  feeding  in  disease  shotild  be  given  a 
secondary   consideration   in   the   study   of   this    subject. 

The  food  must  be  given  in  such  form  that  the  infant 
may  be  able  to  digest  it  easily,  to  assimilate  it,  and 
to  utilize  its  constituents  for  the  purposes  enumerated 
above. 

The  following  factors  must  be  considered  before  esti- 
mating the  composition  and  quantity  of  food  for  infant 
feeding. 

1.  The  clinical  aspects — that  is,  the  general  well- 
being  of  the  infant — must  be  given  equal  importance 
with  the  percentage  and  energy  value  of  the  food 
administered. 

2.  Is  there  a  normal  gain  in  weight  w^hich  an  infant 
must  show  as  a  sign  of  full  health? 

3.  The  qualitative  and  quantitative  chemical  composi- 
tion of  the  food,  the  number  of  calories  available  from 
the  total  administered,  and  the  proportion  of  the  total 
fixated  in  the  body  must  be  taken  into  calculation. 

The  normal  artificially  fed  infant  should  manifest  the 
same  cHnical  evidences  of  good  health  and  progress  as 
are  seen  in  the  breast-fed  infant.  It  should  be  com- 
fortable, which  he  manifests  in  a  happy  disposition.  He 
should  be  a  good  sleeper,  and  awaken  regularly  for  his 
feedings,  and  there  should  be  no  more  occasion  for  his 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     131 

crying  than  in  the  case  of  the  breast-fed  baby.  His  tem- 
perature should  show  maximum  excursions  of  1°  to  2°  F. 
daily.  He  should  have  large  quantities  of  subcutaneous 
fat,  and  his  muscular  tissue  should  be  well  developed. 
The  turgor  of  his  tissues  should  be  normal.  The  latter 
can  be  estimated  by  the  eye  and  by  palpation.  The 
muscles  may  be  taken  between  the  fingers,  and  their  firm- 
ness or  softness  estimated  in  this  way.  By  raising  a  fold 
of  the  skin  we  may  determine  whether  the  panniculus 
adiposus  is  well  developed.  The  stools,  which  of  neces- 
sity must  vary  with  the  diet,  are  firmer  and  drier  and 
much  paler  than  those  of  the  breast-fed  infant,  and  he 
should  pass  one  or  two  daily.  Except  in  the  presence  of 
large  amounts  of  carbohydrates,  and  more  especially  malt 
sugars,  they  are  alkaline  in  reaction,  and  have  a  foul 
odor. 

Therefore,  we  see  that  the  criterion  of  good  health  for 
the  artificially  fed  infant  depends  on  many  things, 
which  together  make  up  the  condition  of  the  infant.  And 
we  again  desire  to  emphasize  that  the  impression  of  the 
general  well-being  of  the  infant  is  a  much  safer  method 
of  estimating  its  progress  than  a  study  of  his  weight- 
curve  alone. 

We  have  learned  to  recognize  the  study  of  the  infant's 
weight  as  one  of  the  simplest  and  most  reliable  clinical 
factors  in  estimation  of  the  infant's  progress.  And  while 
of  necessity  the  diet  of  different  infants  necessary  to 
normal  weight  increases  must  vary  within  very  consider- 
able limits,  the  scale  offers  information  which  is  of  in- 
estimable value. 

The  following  may  be  taken  as  working  averages  for 
comparative  purposes,  and  the  estimation  of  over-  and 
under-  weight  in  infants  coming  under  observation. 


132 


INFANT   FEEDING. 


Average  weight   at   birth  7  pounds    (3200   Gm.,   or   about 

3333  Gm.). 
Average  initial  loss  10  ounces  (300  Gm.)  or  about  one-tenth 

of  the  body  weight  at  birth. 
Birth  weight  regained  usually  by  the  fourteenth  day. 
Weight  is  doubled  at  the  end  of  the  fifth  month. 
Trebled  at  the  end  of  the  first  year. 


Fig,  8. — Scale  for  weighing  infants. 


Average  weekly  gain   during   the  first   five  months)  should 

approximate  5  ounces   (150  Gm.),  during  the  remainder 

of  first  year  4  ounces  (120  Gm.). 
Yearly  gain  during  the  second  year  6  pounds  (2727  Gm.). 
Gain  during  the  third  year  4.5  pounds  (200  Gm.). 
Gain  from  the  fourth  to  the  eighth  year,  4  pounds  annually 

(1800  Gm.). 
Gain  from  the  eighth  to  the  eleventh  year,  6  pounds  annually 

(2700  Gm.). 

An  accurate  scale  is  necessary  equipment  for  proper 
infant  feeding.  Parents  should  be  encouraged  to  pur- 
chase a  balance  scale  with  a  large  scoop. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     133 

However,  it  is  not  sufficient  to  base  the  determination 
of  the  amount  of  food  on  the  weight  of  the  baby  alone, 
since  two  infants  of  the  same  weight  may  have  decidedly 
different  nutritional  requirements,  dependent  upon  vari- 
ous factors.  The  fat  baby  requires  less  food  per  pound 
than  the  thin  baby — the  overfed  less  than  the  underfed 
infant ;  and  the  sick  baby  must  of  necessity  be  fed  within 
its  limits  of  tolerance  during  the  acute  part  of  its  illness, 
and  the  body  losses  must  be  compensated  by  increases  in 
the  diet  beyond  those  which  we  have  learned  to  consider 
as  the  normal  feedings  per  pound  body  weight,  as  its 
tolerance  for  food  permits  during  convalescence. 

A  healthy  infant  should,  therefore,  show  a  regular  gain 
within  certain  limitations.  It  is  not  absolutely  necessary 
for  an  infant  to  add  to  its  body  weight  every  day,  as  daily 
irregularities  are  rather  the  rule  than  the  exception.  The 
relation  of  the  time  of  weighing  to  the  feeding,  defeca- 
tion, and  urination  are  factors  which  must  always  be 
taken  into  consideration.  Therefore  under  normal  condi- 
tions it  is  sufficient  to  weigh  the  infant  once  a  week.  It 
is  especially  wise  to  impress  this  upon  a  nervous  mother. 

Further,  we  must  not  forget  that  the  weight  curve  of 
the  nursing  infant  and  that  of  the  artificially  fed  infant 
differ  widely,  so  that  they  cannot  be  compared  directly. 
The  artificially  fed  infant,  although  in  the  beginning 
gaining  less  than  the  breast-fed  infant,  in  the  course  of  a 
year  reaches  the  same  weight  as  the  breast-fed  infant, 
who  at  first  showed  larger  gains,  but  later  lagged  some- 
what in  its  gains.  Much  more  important  than  the  weight 
itself  is  the  rising  series  of  successive  weight  figures. 

The  clinical  aspects,  that  is,  the  general  zuell-heing  of 
the  infant  must  he  given  equal  importance  zvith  the  per- 
centage and  energy  value  of  the  formula.    In  a  consider- 


134  INFANT   FEEDING. 

ation  of  the  latter  two  important  factors  in  successful 
feeding,  the  chemical  composition  must  he  considered  of 
equal  importance  zanth  the  caloric  value.  Otherwise  one 
meets  with  profound  disturbances  due  to  feeding  of  in- 
sufficient or  excessive  amounts  of  the  components  of  the 
diet,  difficult  of  interpretation. 

It  may  therefore  be  stated  that  the  infant  must  be  fed 
amounts  of  fat,  protein,  carbohydrates,  and  salts  and 
water  suitable  to  its  constitution,  age,  and  physical  de- 
velopment, and  that  these  ingredients  should  be  in  proper 
proportion  and  of  sufficient  quantity  to  meet  the  caloric 
requirements  of  its  tissues  for  growth  and  development. 
Again,  we  must  not  overlook  the  fact  that  the  constitu- 
ents of  the  diet  must  be  in  such  form  as  to  allow  of  nor- 
mal digestion  and  assimilation. 

We  have  spoken  of  the  wide  range  of  tolerance  of  in- 
fants to  their  foods,  and  have  mentioned  that  this,  in  all 
probability,  accounts  to  a  very  great  degree  for  the  fact 
that  so  many  men  have  been  successful  in  the  feeding  of 
infants  on  a  variety  of  mixtures  which  varied  greatly 
both  quantitatively  and  qualitatively.  There  is  in  all 
probability  another  factor  which  is  important  in  explain- 
ing these  successes,  namely,  the  fact  that  to  a  certain  ex- 
tent fats,  carbohydrates,  and  proteins  are  interchange- 
able in  their  metabolic  functions. 

Proteins.  After  passing  through  the  intestinal  wall 
proteins  have  three  functions  to  perform :  ( 1 )  to  replace 
used  protein  (lost  through  urine,  sweat,  digestive  juices, 
cell  destruction,  etc.)  ;  (2)  to  satisfy  cell  growth,  which 
would  be  impossible  without  proteins;  (3)  to  furnish 
fuel  for  part  of  the  dynamic  loss  (fats  and  carbohydrates 
are  the  natural  fuel,  the  protein  combustion  being 
incidental  only). 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     135 

There  is  three  times  as  much  protein  in  cow's  milk  as 
in  human  milk.  The  reason  for  this  is  obvious,  when 
we  recall  that  the  ratio  of  the  growth  of  the  calf  to  that 
of  the  infant  is  about  as  2  to  L  Furthermore,  the  protein 
in  cow's  milk  consists  chiefly  of  casein  (3.02  per  cent.) 
and  little  lactalbumin  (0.53  per  cent.),  while  human  milk 
contains  0.59  per  cent,  of  casein  and  1.23  per  cent,  of 
lactalbumin. 

The  proteins  are  characterized  by  containing  nitrogen. 
If  the  nitrogen  is  determined  in  the  food  eaten  during  the 
period  of  the  experiment,  it  is  evident  that  a  balance  may 
be  struck  which  will  determine  whether  the  body  is  re- 
ceiving in  the  food  as  much  protein  nitrogen  as  it  is 
metabolizing  and  eliminating  in  the  excreta.  If  there  is 
a  plus  balance  in  favor  of  the  food,  it  is  evident  that  the 
body  is  laying  on  or  storing  protein,  while  if  the  balance 
is  minus,  the  body  must  be  losing  protein.  During  the 
period  of  growth,  in  convalescence,  etc.,  the  body  does 
store  protein,  and  under  these  conditions  the  balance  is  in 
favor  of  the  food  nitrogen. 

It  is  important  also  to  bear  in  mind  that  nitrogen  or 
protein  equilibrium  may  be  established  at  different  levels 
in  order  to  explain  the  good  feeding  results  with  what 
may  be  an  excessive  protein  diet.  That  is,  an  infant  who 
has  been  receiving  1.5  Gm.  of  protein  per  Kg.,  and  who 
has  excreted  the  greater  part  thereof,  retaining  only  such 
portion  as  is  needed  for  the  body  growth,  will,  upon 
being  fed  larger  quantities,  retain  only  a  similar  amount 
for  body  growth,  excreting  the  difference  in  the  urine, 
sweat,  and  feces.  The  true  cell  life  does  not  depend  on 
what  has  been  ingested,  absorbed  and  temporarily  fixated, 
to  be  eliminated  soon  afterwards,  but  on  the  constant  and 
stable  fixation.     The  body  may  become  adapted  to  over- 


136  INFANT   FEEDING. 

feeding  and  overfixation,  but  this  is  usually  of  only  a 
short  duration,  and  the  excretion  of  the  oversupply  is 
never  long  delayed.  Experimentally,  it  is  found  that 
there  is  a  certain  low  limit  of  proteiri  which  just  suffices 
to  maintain  nitrogen  equilibrium.  Rubner  found  that 
when  5  per  cent,  of  the  total  energy  intake  was  in  protein 
that  it  was  sufficient  for  maintenance,  and  that  even  4 
per  cent,  was  sufficient  to  supply  its  actual  need  when 
amply  supplied  with  carbohydrate.  However,  7  per  cent, 
was  necessary  to  keep  up  the  normal  growth. 

Examination  of  the  dietaries  of  civilized  races  shows 
that,  on  the  average,  100  to  120  Gm.  of  protein  are  used 
daily  by  an  adult  man.  A  variable  portion  of  this  amount 
passes  into  feces  in  undigested  form,  but  we  may  assume 
that  about  100  to  105  Gm.  are  absorbed,  and  actually 
metabolized  in  the  body.  If  we  take  into  account  the 
weight  of  the  body,  this  amount  of  protein  may  be  esti- 
mated as  equivalent  in  round  number  to  1.5  Gm.  of  pro- 
tein, or  0.23  Gm.  nitrogen,  per  kilogram  of  body  weight. 
Chittenden  believes  that  the  daily  quota  of  protein  per 
kilogram  of  body  weight  may  be  reduced  to  one-half  this 
quantity,  from  1.5  Gm.  to  0.75  Gm.  of  protein,  or  0.12 
Gm.  of  nitrogen,  per  kilogram  body  weight. 

If  the  body  can  be  kept  in  good  condition  upon  0.75 
Gm.  per  kilogram  per  day,  will  an  ingestion  of  more  than 
this  (say  twice  as  much)  prove  injurious  or  beneficial  or 
indifferent  to  the  body?  The  full  and  satisfactory 
answer  to  this  question  must  be  deferred  until  more  ex- 
perience is  obtained.  The  newer  conceptions  in  regard 
to  the  digestion  and  nutritive  history  of  the  protein  foods 
certainly  seem  to  favor  the  adoption  of  a  low  protein  diet. 
Mankind,  when  left  to  the  guidance  of  the  natural  appe- 
tites, has  always,  when  possible,  adopted  the  high  pro- 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     137 

tein  level  of  90  to  100  Gm.  per  day.  That  mankind  has 
made  a  mistake  in  adopting  the  higher  protein  level  can 
hardly  be  claimed  on  the  basis  of  our  present  knowledge. 

The  chief  demands  for  protein  are  to  compensate  for 
wear  and  tear,  and  to  provide  for  growth. 

Sugars  and  starches,  when  added  to  a  diet  sufficient  to 
meet  an  infant's  needs,  will,  temporarily  at  least,  cause 
a  greater  nitrogen  retention.  Fats  have  little  or  no  such 
influence.  Nitrogen  to  be  retained  must  be  built  up  into 
living  protoplasm,  and  to  accomplish  this  salts  must  be 
available.  Unless  they  are  present,  the  nitrogen  is  again 
excreted.  Approximately  1.7  Gm.  of  ash  are  retained 
for  each  1  Gm.  of  nitrogen  (Howland),  or  0.3  Gm.  of 
ash  for  each  1  Gm.  of  protein. 

Hoobler  believes  that  the  protein  needs  of  the  infant 
are  supplied  when  7  per  cent,  of  its  caloric  needs  is  fur- 
nished in  protein  calories,  and  states  that  three-fourths  of 
a;n  ounce  of  whole  or  skim  milk,  or  0.6  Gm.  of  protein 
per  pound  body  weight  is  sufficient  to  meet  these  needs. 
To  make  up  the  deficiency  in  the  caloric  needs,  he  adds 
for  each  ounce  of  whole  milk  one-third  of  an  ounce  of 
sugar  or  cereal. 

Rubner  was  able  to  promote  normal  growth  when  0.7 
per  cent,  of  the  total  energy  intake  was  in  proteins. 

Cowie  finds  the  protein  requirement  in  a  two-  to 
twelve-  months  infant  to  average  1.1  Gm.  per  pound. 

Dunn  states  that  1.0  Gm.  to  1.5  Gm.  of  protein  daily 
per  kilogram  of  body  weight  is  necessary  for  the  nor- 
mal infant. 

Camerer  states  the  following  requirements  for  each 
kilogram  of  body  weight  in  a  child  between  2  and  4 
years  of  age:  proteins,  3.6  Gm. ;  fat,  3.1  Gm. ;  carbohy- 
drates, 9.2  Gm. ;  and  water,  75.3  Gm, 


138  INFANT   FEEDING. 

It  has  been  our  custom  to  feed  approximately  1.5 
ounces  of  milk  to  a  pound  of  body  weight  to  the  healthy 
normal  infant,  which  would  represent  1.5  Gm.  of  protein 
per  pound  of  body  weight. 

Notwithstanding  what  has  been  said  on  theoretical  and 
experimental  studies  of  the  protein  needs  of  the  arti- 
ficially fed  infant  as  compared  with  the  amount  of  pro- 
tein as  received  by  the  breast-fed  infant,  it  must  be 
granted  that  casein,  the  chief  protein  of  cow's  milk,  as 
given  in  ordinary  dilutions  to  the  infants  is  sufficient  to 
cover  entirely  the  protein  needs  of  the  infant,  and  that 
its  excess  rarely  causes  nutritional  disturbances  when 
the  tendency  to  large  curd  formation  is  prevented  by 
boiling  or  alkalinizing  the  milk. 

We  have  therefore  continued  to  use  the  protein  as 
contained  in  1.5  ounces  of  milk  per  each  pound  of  body 
weight  of  the  normal  infant,  and  in  the  underfed  we 
have  not  hesitated  to  increase  this  quantity  to  an  amount 
equal  to  2  or  even  2.5  ounces  per  pound,  thereby  approxi- 
mating 1.5  ounces  per  pound  of  what  the  baby  should 
weigh  for  its  age.  Increases  of  milk  in  the  diet  must  be 
gradual,  the  additions  being  guided  by  the  child's  ability 
to  handle  the  food.  From  what  has  been  stated,  it  may 
be  inferred  that  it  is  wise  to  establish  the  protein  content 
in  a  diet  which  may  then  be  supplemented  by  fats,  carbo- 
hydrates, and  salts,  because  protein  is  the  tissue  builder 
and  must  necessarily  be  a  basic  constituent  of  all  diets. 

Fats.  Fats  are  necessary  to  normal  growth  and 
nutrition  of  the  human  body.  But  they  to  a  greater  ex- 
tent than  the  other  food  elements  can  be  replaced  by 
proteins  and  sugars,  more  especially  the  latter.  This  ex- 
plains the  fact  that  infants  fed  on  low  fat  mixtures,  more 
especially  proprietary  foods,  such  as  condensed  milk,  will 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     139 

continue  to  gain  in  weight.     However,  such  development 
cannot  be  considered  as  normal. 

Fats  furnish  part  of  the  heat  energy  necessary  to  main- 
tain the  body  temperature.  They  are  stored  as  a  reserve 
food.  The  fat  is  a  protein  saver,  and  when  supplied  in 
proper  amount  but  little  protein  is  used  for  the  produc- 
tion of  animal  heat,  thereby  allowing  for  greater  protein 
retention  for  the  growth  of  the  body  tissues. 
.  Under  normal  conditions,  the  average  infant  will  digest 
from  2  to  3.5  per  cent,  of  fats.  However,  some  infants 
digest  fat  badly,  and  when  a  fat  intolerance  is  once  estab- 
lished it  is  overcome  only  with  great  difficulty.  In  such 
cases  it  is  necessary  to  throw  the  burden  of  furnishing 
the  extra  food  necessary  on  the  carbohydrates;  and  car- 
bohydrates in  large  quantities  are  unsafe  food  for  the 
infant.  Such  a  catastrophe  should  be  avoided,  as  infants 
receiving  an  insufficient  amount  of  fat  rarely  thrive  satis- 
factorily. We  should  therefore  aim  to  stay  within  safe 
limits.  And  it  has  been  our  experience  that  most  infants 
will  thrive  well  on  the  amount  of  fat  furnished  by  the 
use  of  1.5  to  2.0  ounces  of  whole  milk  per  pound  body 
weight.  When  moderate  quantities  of  fat  are  fed,  we 
avoid  the  acute  clinical  picture  of  fat  overfeeding  asso- 
ciated with  vomiting  and  diarrhea,  and  not  infrequently  a 
high  temperature,  and  occasionally  convulsions.  On  the 
other  hand,  the  moderate  quantity  of  fat  contained  in  the 
diet  necessitates  a  high  percentage  of  carbohydrate  feed- 
ing, which  in  turn  avoids  the  so-called  fat-soap  stools, 
with  their  tendency  to  rob  the  body  of  an  excessive 
amount  of  calcium  and  magnesium.  For  the  formation 
of  a  fat-soap  stool  it  is  necessary  that  we  have  an  insuffi- 
ciency of  carbohydrates  and  a  relative  excess  of  proteins, 
as  putrefaction  is  necessary  for  the  production  of  these 


140  INFANT   FEEDING. 

stools,  while  fermentation  opposes  their  formation.  And 
in  the  presence  of  excessive  fermentation  the  putrefac- 
tion is  limited. 

It  may  therefore  be  stated  that  while  the  tolerance  for 
fat  of  cowl's  milk  varies  greatly  in  different  individuals, 
most  infants,  however,  will  digest  and  assimilate  1.5  to 
2.0  Gm.  of  fat  per  pound  body  weight  daily,  which  is 
the  quantity  represented  in  1.25  to  2.00  ounces  of  average 
cow's  milk.  This  quantity  will  also  supply  the  body 
needs  for  growth  and  development,  when  associated  with 
a  sufficient  carbohydrate  content  in  the  food. 

Carbohydrates.  They  are  used  chiefly  to  supply 
heat  and  energy,  to  supply  in  part  material  for  fat  foun- 
dation, thereby  replacing  in  part  the  fat  waste.  Because 
of  their  high  caloric  value  they  supply  a  large  amount  of 
energy.  They  are  efficient  sparers  of  protein,  and  will 
supply  energy  in  case  of  fat  insufficiency  in  the  diet. 
Synthetically,  they  are  converted  into  glycogen  in  the 
body.  Fat  is  formed  from  sugar  by  the  subcutaneous 
cells,  which  are  especially  adapted  to  this  function. 
Sugar  is  reduced  to  CO2  and  water,  which  may  be  meas- 
ured by  the  respiratory  metabolism.  Normally,  sugar  is 
absorbed  from  the  small  intestine  in  greater  part,  and  is 
not  found  in  the  feces.  If  absorbed  in  sufficient  quantity, 
they  will  cause  a  rapid  increase  in  weight.  When  insuffi- 
cient carbohydrate  is  supplied  to  the  body,  it  is  obtained 
by  breaking  down  the  body  protein. 

In  general,  infants  have  a  very  high  carbohydrate  tol- 
erance— much  higher  than  the  adult — and  even  infants 
suffering  from  certain  forms  of  nutritional  disturbance 
may  retain  their  ability  to  metabolize  sugar,  even  though 
it  may  have  been  reduced  for  fat  and  proteins.  Some 
infants    do    not   handle    sugar    well,    and   among   these 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     141 

are    certain     forms    of    gastro-intestinal     disturbances, 
eczema,  etc. 

During  recent  years  much  has  been  written  on  the 
superiority  of  one  form  of  carbohydrate  over  the  other. 
We  can  practically  exclude  the  monosaccharides  in  the 
consideration  of  the  subject,  and  speak  only  of  the  di- 
saccharides,  of  which  lactose,  saccharose  (cane-sugar), 
and  maltose  are  the  ones  used  in  infant  feeding,  of  the 
polysaccharides,  as  represented  by  the  cereal  flours  and 
dextrin,  and  last,  of  the  mixture  of  disaccharides  and 
polysaccharides,  together  with  other  substances,  these 
mixtures  being  represented  by  the  various  infant  foods 
on  the  market. 

Sugars.  Of  recent  years  there  has  been  a  consider- 
able discussion  on  the  comparative  nutritive  value  of 
milk-sugar  (lactose)  and  cane-sugar  (saccharose).  In 
our  own  experience  we  have  found  little  to  recommend 
one  over  the  other  in  so  far  as  their  nutritive  value  and 
the  limit  of  tolerance  is  concerned,  except  as  we  have 
seen  a  laxative  effect  from  the  use  of  lactose,  which  is 
usually  not  present  with  the  same  quantities  of  sac- 
charose. This  is,  however,  not  seen  in  all  infants.  Mal- 
tose is  not  used  pure,  but  as  previously  stated,  in  the 
form  of  various  compounds  in  infant  feeding.  It  may 
therefore  be  stated  that  cane-sugar  will  answer  all  re- 
quirements for  most  cases,  but  should  rarely  be  used  in 
amounts  larger  than  3  to  4  per  cent,  of  the  total  mixture, 
because  of  its  intense  sweetness.  It  may  be  also  recom- 
mended from  the  standpoint  of  economy. 

In  the  presence  of  extreme  colic,  it  is  often  wise  to 
change  the  form  of  sugar  that  the  infant  is  receiving,  as 
the  individual  infant  may  show  an  intolerance  for  one  or 
the  other  sugar. 


142  INFANT   FEEDING. 

Quantities.  Cane-  and  milk-  sugar  may  be  added  to 
the  diet  in  the  following  quantities : 

Infants  under  6  pounds — 0.5  ounces  in  twenty-four  hours. 
Infants   between  6   and   10  pounds — 0.75   to    1.00   ounces   in 

twenty- four  hours. 
Infants  between   10  and   14  pounds — 1.00  to   1.25   ounces  in 

twenty- four  hours. 
Infants  over  14  pounds — 1.5  ounces  in  twenty-four  hours. 

Approximately,  therefore,  about  1  ounce  of  sugar  is 
added  in  twent}-four  hours  for  each  10  pounds  of  body 
weight,  or  about  %oo  of  the  body  weight  in  twenty-four 
hours. 

Including  the  sugar  contained  in  the  milk,  and  exclu- 
sive of  the  cereal,  the  infant  should  average  from  4.0 
Gm.  to  6.0  Gm.  of  carbohydrates  per  pound  body  weight 
to  furnish  its  needs. 

Dextrin  and  maltose  compounds  can  frequently  be 
added  to  the  diet  to  advantage  in  the  presence  of  sta- 
tionary weight.  It  must,  however,  be  remembered  that 
their  relationship  to  constipation  varies  greatly,  depend- 
ent upon  their  malt,  dextrin,  and  potassium  carbonate 
content.  Thus  we  find  that  those  of  the  proprietary 
foods  containing  a  considerable  percentage  of  dextrin,  in 
the  absence  of  potassium  carbonate,  are  constipating 
(Horlick's  malt  food.  Mead's  dextrimaltose)  ;  while 
those  with  a  higher  maltose  content,  together  with  potas- 
sium carbonate  (Borcherdt's  dri  malt  soup  and  Mellin's 
food),  are  laxative. 

Cereal  Flours.  They  can  be  added  to  the  diet  of 
most  infants  early  in  life  in  quantities  varying  from  1  to 
2  per  cent,  of  the  total  quantity  of  the  milk  mixture  to 
good  advantage.  Such  an  addition  to  the  food  fre- 
quently results  in   rapid  weight  increases,   and  general 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     143 

improvement  of  the  infant.  In  older  infants,  cooked 
cereals  may  be  used  in  place  of  the  starch  solutions.  We 
have  reason  to  believe  from  clinical  experience  that  the 
flours  made  from  cereals  have  a  decided  advantage  over 
the  dextrinized  flours  on  the  market.  Whether  this  is 
due  to  vitamines  contained  in  the  former  or  to  some 
other  distinctive  property  we  are  unable  to  state.  The 
cereals  also  have  a  decided  influence  on  the  calcium 
and  magnesium  balance.  The  cereals  cause  retention  of 
these  salts,  which  may  have  a  favorable  influence  on  the 
weight. 

Salts.  Salts  are  necessary  in  digestion,  and  in  every 
step  of  metabolism,  from,  absorption  to  excretion  and 
secretion.  The  role  of  salts  in  both  normal  and  path- 
ological conditions  has  been  given  constantly  increasing 
importance  in  the  last  few  years. 

Human  milk  contains  0.2  Gm.  of  ash  in  100  mils,  and 
cow's  milk  0.78  Gm.  of  ash  in  100  mils.  The  difference 
in  percentage  in  the  human  and  in  the  cow's  milk  is 
equalized  by  the  body  using  only  what  is  necessary  for  its 
life  and  growth.  The  salts  are  absolutely  necessary  for 
the  life  of  the  organism. 

While  all  the  salts  are  in  larger  percentage  in  cow's 
milk  than  in  human  milk,  the  relative  proportions  of  the 
different  salts  differ  greatly.  In  general,  cow's  milk  con- 
tains relatively  a  very  large  amount  of  calcium  phosphate, 
while  the  proportion  of  potassium  salts  and  iron  in  cow's 
milk  as  compared  with  human  milk  is  relatively  small. 
There  is  a  great  difference  in  the  form  in  which  phos- 
phorus is  present  in  human  and  in  cow's  milk.  In  human 
milk  three-quarters  of  the  phosphorus  is  in  organic  com- 
bination, while  in  cow's  milk  only  one-quarter  is  in  or- 
ganic combination.     The  iron  in  neither  human  milk  nor 


144  INFANT   FEEDING. 

in  cow's  milk  is  sufficient  to  meet  the  demands  in  the 
first  year  of  Hfe;  the  infant  must  depend  on  the  iron 
stored  during  fetal  life.  The  following  table  gives  per- 
centages of  different  salts  in  100  parts  of  ash  of  the 
human  and  of  the  cow's  milk. 

K2O        NaO        CaO       MgO      F2O3       P2O5         CI 

Human  milk  . .  30.1        13.7      13.5       1.7       0.17      12.7     21.8 
Cow's  milk   ...  22.14     15.9     20.05     2.63     0.04     24.7     21.27 

The  inorganic  salts  in  human  milk  consist  mainly  of 
the  alkaline  bases,  potassium  and  sodium,  while  in  cow's 
milk  the  calcium  and  magnesium  account  in  greater  part 
for  the  difference  in  the  total  mineral  content  of  the  two 
milks.  From  the  preceding  table  it  becomes  evident  that 
in  higher  dilutions  of  cow's  milk  the  potassium  and  sod- 
ium content  must  suffer  most.  Such  a  long-continued 
feeding  of  an  insufficient  amount  of  potassium  and 
sodium  may  affect  the  infant's  development  to  a  serious 
extent.  Human  milk  also  contains  about  four  times  as 
much  iron  as  cow's  milk,  and  dilution  of  cow's  milk  re- 
sults in  a  decrease  in  the  iron  content,  which  must  not  be 
carried  too  far  unless  supplemented  by  other  iron-con- 
taining food. 

"Therefore  the  mineral  metabolism  of  the  artificially 
fed  infant  differs  greatly  from  that  of  the  breast-fed  in- 
fant. The  infant  receiving  cow's  milk,  with  its  greater 
salt  contents,  lives  on  a  higher  plane  of  mineral  metab- 
olism than  does  the  one  receiving  the  breast  milk.  He 
absorbs  60  per  cent,  of  the  total  ash,  and  retains  only 
about  15  per  cent.,  while  the  breast-fed  infant  utilizes  to 
the  full  his  opportunities,  and  absorbs  80  per  cent,  of 
the  ash,  and  retains  40  to  50  per  cent.  In  the  majority 
of  infants  this  excessive  salt  intake  undoubtedly  does  no 
harm ;  the  surplus  is  not  absorbed,  or  is  merely  eliminated. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     145 

"Sodium  and  potassium  are  usually  well  retained,  un- 
less severe  diarrhea  is  present,  or  there  is  an  excess  of 
fat  or  of  sugar  in  the  diet.  Under  such  circumstances 
they  are  lost,  and  the  loss  is  badly  borne,  and  cannot  in- 
definitely be  continued.  When  all  available  alkalies  have 
been  drawn  on,  the  infant  breaks  down  his  own  tissue 
to  furnish  more  of  these  substances,  which  is  an  explana- 
tion, for  a  part  at  least,  of  the  excessive  nitrogen  excre- 
tion under  such  conditions.  When  diarrhea  ceases,  and 
the  intake  is  sufficient,  a  positive  balance  is  rapidly 
instituted. 

'The  metabolism  of  calcium  has  been  largely  studied, 
on  account  of  its  close  relationship  to  rickets  and  tetany. 
Calcium  is  so  largely  excreted  by  the  bowel  that  it  is  im- 
possible to  say  how  much  is  absorbed,  plays  part  in  the 
organism,  and  is  then  excreted  by  the  intestine,  either  be- 
cause it  is  in  excess,  or  because  (as  in  the  case  of  rickets) 
the  body  cannot  utilize  it.  This  is  also  true  of  mag- 
nesium, and  to  a  much  less  extent  of  sodium  and  potas- 
sium" (Howland). 

The  salts  are  necessary  for  building  up  of  the  body  tis- 
sue, and  each  gram  of  protein  retained  and  built  into 
body  tissue  requires  approximately  one-third  of  a  gram 
of  ash. 

Water.  The  quantity  of  water  necessary  for  the  in- 
fant is  not  only  of  theoretical,  but  also  of  vast  practical 
importance.  There  are  many  breast-fed  infants  who  ob- 
tain a  food  which  is  very  rich  in  other  nutritive  sub- 
stances, but  contains  only  a  small  amount  of  water. 
These  infants  may  not  gain  well  in  weight  unless  water 
is  added.  And,  besides  that,  in  sick  infants  it  is  occa- 
sionally necessary  to  feed  them  (especially  in  cases  of 
vomiting,  anorexia,  infections)   with  concentrated  food, 

10 


146  -        IXFAXT    FEEDING. 

and  in  these  cases  the  total  water  intake  necessary  must 
not  be  lost  sight  of. 

In  regard  to  water  retention  Meyer*  found  three 
classes  of  cases:  (1)  those  in  which  there  was  a  de- 
crease in  weight  when  the  food  was  concentrated,  and 
the  weight  increased  only  after  addition  of  water;  (2) 
those  where  the  weight  remained  the  same  on  a  concen- 
trated food,  and  there  was  an  increase  after  the  addition 
of  water;  and  (3)  those  in  which  the  addition  of  water 
made  no  difference,  but  who  did  well  on  a  concentrated 
food.  He  found  that  the  water  need  decreased  with  in- 
creasing age — that  on  artificial  food  the  water  needs 
were  89  Gm.  per  Kg.  body  weight  in  twenty-four  hours 
at  the  beginning,  and  80  Gm..  at  the  end  of  the  first  year ; 
while  in  breast-fed  infants  the  water  need  amounted  to 
134  Gm.  to  140  Gm.  per  Kg.  in  twenty-four  hours. 

Water  is  absolutely  necessary  for  life,  and  manifesta- 
tions of  life  are  impossible  without  w^ater.  The  lack  of 
or  inadequacy  of  water  are  much  more  dangerous  to  the 
infant  than  a  corresponding  deficiency  in  the  food.  Ex- 
cess of  water,  however,  exerts  also  an  unfavorable  influ- 
ence on  the  organism.  Immunity  is  considerably  de- 
pendent on  the  physiological  water  content  of  the  body. 

Estimation  of  the  Caloric  Contents  of  the  Food  as  a 
Check  on  Over-  and  Under-  feeding.  Calorimetric 
estimations  of  the  diet  must  be  considered  only  as  a  check 
on  under-  and  over-  feeding,  and  not  as  a  method  of 
feeding.  In  the  infant  whose  diet  usually  consists  of 
milk  or  its  constituents  and  sugar  and  cereal  flours,  this 
is  a  very  simple  matter.  It  should,  however,  be  remem- 
bered that  there  are  considerable  variations  in  the  caloric 


'^  L.  F.  Meyer,  Zschrft.  f .  Ivhlk.  1912,  5,  1. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     147 

requirements  of  normal  babies.  The  fat  and  well-nour- 
ished infant  will  require  less  food  to  maintain  its  body 
heat  than  the  emaciated  one.  The  sick  baby  will  rarely 
be  able  to  digest  its  full  needs  as  estimated  by  its  body 
weight.  Therefore  as  in  every  other  phase  of  infant 
feeding,  the  individual  infant  must  be  given  primary 
consideration.  It  must  be  remembered  that  the  nutri- 
tion of  the  baby  depends  upon  the  quantity  of  the  food 
assimilated,  and  not  upon  the  quantity  ingested.  Less 
food  is  being  absorbed  and  utilized  in  the  infant  with  a 
deficient  power  of  digestion,  and  overfeeding  will  re- 
tard the  infant's  progress.  A  comparative  estimate  of 
the  infant's  diet,  with  a  theoretical  minimum,  is  of  special 
value  in  cases  of  doubt  as  to  whether  the  retarded  prog- 
ress is  due  to  insufficient  food  or  defective  digestion  and 
assimilation. 

Under  this  system  the  physician  reckons  the  minimum 
daily  caloric  requirements,  either  from  the  present 
weight  of  the  baby  or  what  it  should  weigh  in  health, 
and  then  chooses  the  food  necessary  to  meet  this  re- 
quirement, bearing  in  mind  that  the  fat,  carbohydrate  and 
protein  contents  of  the  diet  must  not  only  meet  the 
caloric  requirements,  but  also  be  properly  proportioned, 
so  as  to  contain  the  proper  number  of  grams  of  each  of 
the  constituents  to  meet  the  infant's  needs  for  growth 
and  development. 

Heubner  and  Rubner  gave  us  the  first  definite  estimates 
as  to  the  caloric  needs.  They  found  that  the  average 
healthy  infant  after  birth  requires  on  the  average  100 
calories  per  kilogram  body  weight,  from  six  months  to 
the  end  of  the  first  year — approximately  85  calories  per 
kilogram  body  weight — and  that  70  calories  per  kilogram 
body  weight  is  the  energy  quotient  on  which  a  baby  would 
maintain  a  weight  equilibrium. 


148  IXFAXT   FEEDING. 

Dunn  places  this  minimum  caloric  requirement  for 
artificially  fed  infants  as  follows : 

Birth  to  6  months  , . .    120  cal.  per  Kg.   (55  cal.  per  pound) 

6  to  12  months   100     "      "       "     (45     "       "  "    ) 

12  to  24  months   90    "      "       "     (40    "      "  "    ) 

Dennett^  gives  the  following  figures : 

Fat  infants  over  4  months  of  age  . .  40  to  45  cal.  per  pound 
Average  infants  under  4  months  of 

age  and  moderately  thin  infants  of 

any  age   50    "   55     "      " 

Emaciated  infants  (varying  with  the 

degree  of  emaciation)    60    "  65     "       "         " 

Bradyt  gives  the  following  figures  as  his  experience 
with  ii)stitutional  children:  50  to  55  calories  for  each 
pound  during  the  first  6  to  8  months  of  life. 

Our  own  experience  coincides  with  those  of  Dennett 
and  Brady  in  that  we  find  that  the  figures  of  Heubner  do 
not  meet  the  requirements  of  any  except  the  well-nour- 
ished infants.  Underfed  infants  not  suffering  from  de- 
composition (marasmus)  must  be  fed  food  of  a  higher 
caloric  value  per  pound  body  weight  than  the  normal  in- 
fants, and  while  such  infants  must  be  fed  minimal  quan- 
tities when  first  seen,  for  a  proper  gain  in  weight  their 
normal  weight  must  be  estimated  and  their  diet  gradually 
approximated  to  the  needs  of  the  weight  that  they  should 
normally  have. 

Average  infants  under 

2  months  of  age  . .  30  to  45  cal.  per  lb    (  65  to  100  per  Kg.) 
Average  infants  over 

2  months  of  age  . .  45    "   55      "      "     "    (100   "   120  .  "      "   ) 


*  Infant  Feeding,  J.  B.  Lippincott  Co.,  Philadelphia,  page  58. 

t  J.  M.  Brady,  Institutional  Care  of  Infants,  Archives  of  Fed., 
1917,  34,  356. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     149 

Premature  and  thin 
infants  under  2 
months  of  age   50  to  65  cal.  per  tb   (110  to  140  per  Kg.) 

Thin  infants  older 
than  2  months,  de- 
pending upon  their 
general  condition    .   55    "   70     "       "      "    (120    "   150    "       "    ) 

During  the  first  few  weeks  of  life  of  the  artificially  fed 
infant  it  is  usually  difiicult  to  approximate  these  figures 
(see  p.  159). 

Increases  in  quantity  of  food  should  always  be  gradual, 
especially  in  the  presence  of  malnutrition,  and  the  infant 
carefully  observed,  and  increases  made  only  as  the  toler- 
ance for  food  permits. 

Estimation  of  the  caloric  contents  of  the  food  is  not  a 
feeding  method  and  should  be  used  only  as  a  check  on 
over-  and  under-  feeding,  the  scale,  stool,  and  general 
condition,  and  particularly  the  disposition  of  the  infant, 
being  the  ultimate  guide  for  dietetic  changes. 

Energy  quotient  is  the  number  of  calories  which  the 
infant  is  getting  per  pound  or  per  kilogram  of  body 
weight.  To  determine  the  energy  quotient  of  the  diet 
multiply  the  number  of  ounces  of  each  food  ingredient  of 
the  food  mixture  by  their  caloric  values,  add  the  products 
and  divide  the  sum  by  the  number  of  pounds  or  kilo- 
grams of  the  baby's  weight. 

Caloric  Values  of  1  oz.  (30  Gm.)  of  Various  Foods. 

Calories 
Cow's  milk   21 

Human  milk  21 

16  per  cent,  cream  54 

Skim  milk  11 

Buttermilk   11 


150  IXFAXT    FEEDING. 

Calories. 
Buttermilk  mixture   .- 21 

Albumin  milk    12 

Chymogen  milk  21 

Keller's  malt  soup   25 

Cane-sugar    (by  weight )    120 

Maltose-dextrin  compounds   (average)    110 

Malt-soup  extract,  dry,  by  weight 90 

''                 "           "     by  measure  132 

Flour,  by  weight  100 

Cereal  waters  (1  oz.  cereal  to  quart)    3 

The  following  table  gives  equivalents  of  1  ounce  by 
weight  and  the  domestic  measures  of  carbohydrates  used 
in  artificial   feeding  of  infants : 


Cane-sugar  .... 

By 
weight 

.     1    OZ. 

By 
measure 

1.00  oz. 

Table-      Dessert- 
spoonfuls spoonfuls 
leveled  with  a 
2            3 

Tea- 
spoonfuls 
knife. 

6 

Milk-sugar    .... 

1     '' 

1.50 

i< 

3 

4.5 

9 

Dextri-maltose 

1.50 

a 

3 

4.5 

9 

Flour   (wheat) 

-    2.25 

<( 

5 

7.5 

15 

Flour   (barley) 

1.50 

a 

3 

4.5 

9 

Barley    (pearl) 

2.50 

'•' 

5 

8 

15 

Oats    (rolled)    . 

2.50 

a 

5 

8 

15 

1   tablesboon 

ful  =  1.5 

dessert' 

spoonfuls  =  3 

teaspoonfuls. 

Practical  Application  of  Milk  Dilutions  with  Addi- 
tion of  Carbohydrates  in  Infant  Feeding.  In  the  appli- 
cation of  the  rules  for  the  feeding  of  normal,  healthy 
infants,  it  must  be  remembered  that  each  infant  must  be 
fed  to  meet  its  individual  requirements,  and  the  rules 
modified  so  as  to  meet  the  demands  of  the  individual 
baby.  If  milk  dilutions,  with  the  addition  of  carbohy 
drates  are  used,  the  simplest  and  most  natural  standard 
would  be  one  that  would  tell  us  how  much  milk  and  car- 
bohydrates per  pound  or  per  kilogram  body  weight  the 
baby  should  get.  To  be  exact  we  should  express,  or  at 
least  be  aware,  of  the  number  of  grams  of  proteins,  fats, 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     151 

carbohydrates  and  salts  that  the  infant  is  receiving  for 
each  pound  of  its  body  weight.  We  beHeve  that  if  statis- 
tics on  infant  feeding  were  collected  on  this  basis  rather 
than  in  percentages  of  the  ingredients  in  the  milk  mix- 
tures (the  total  mixture  being  of  such  variable  quantity) 
the  collected  data  would  be  far  more  valuable  as  a  basis 
for  future  work  in  infant  feeding. 

In  every  instance  the  general  health  of  the  infant  is  of 
the  greatest  importance  in  estimating  its  capacity  for  as- 
similating the  diet. 

To  meet  protein  and  fat  requirements,  the  average  nor- 
mal infant  will  require  each  day  a  minimum  of  ly^ 
ounces  (45  mils)  of  cow's  milk  per  pound  of  body 
weight,  exclusive  of  the  sugar  and  starch  which  are 
added  in  preparation  of  the  mixture. 

Practical  experience  has  taught  us  that  infants  under 
five  months  of  age  will  frequently  require  amounts  ap- 
proximating 2  ounces  (60  mils)  of  cow's  milk  per  pound 
body  weight,  except  during  the  first  few  weeks  of  life, 
when  smaller  quantities  of  whole  or  skim  milk  are  indi- 
cated (see  p.  159).  With  the  institution  of  a  mixed  diet, 
the  infant  thrives  with  less  milk  per  pound  body  weight. 

In  beginning  feeding  with  cow's  milk,  mixtures  must 
always  be  started  as  weak  formulae,  more  often  using 
only  1  ounce  (30  mils)  of  cow's  milk  to  a  pound  body 
weight,  gradually  increasing  the  strength  to  meet  the 
infant's  needs. 

Underweight  infants  should  at  first  be  fed  according 
to  their  present  weight,  gradually  increasing  the  strength 
of  the  mixture  as  rapidly  as  consistent  with  the  baby's 
ability  to  handle  the  diet,  and  thus  approximating  the 
needs  of  a  full  weight  baby  of  the  same  age.     These 


152  INFANT   FEEDING. 

babies  will  frequently  take  over  2  ounces   (60  mils)   of 
milk  per  pound  body  weight. 

Number  of  Feedings  in  Twenty-four  Hours.  Three- 
hour  intervals  at  the  start,  with  7  feedings  in  twenty- 
four  hours,  for  the  first  month  (6-9-12-3-6-10-2),  6  feed- 
ings during  the  second  and  the  third  month  (6-9-12-3- 
6-10),  5  feedings  by  the  fourth  to  the  fifth  months  (6-10- 
2-6-10),  according  to  the  individual  needs  of  the  child. 

Premature  and  delicate  infants  with  a  tendency  to 
vomit  are  exceptions,  and  may  be  fed  smaller  amounts  at 
more  frequent  intervals,  even  two  hours,  if  indicated. 
Catheter  feeding  may  be  necessary,  in  which  case  the 
longer  interval  will  usually  answer. 

Amounts  at  Each  Feeding.  From  birth  to  the  fifth 
month  the  average  healthy  infant  may  be  satisfied  with  an 
amount  of  food  approximating  2  ounces  more  per  feed- 
ing than  the  infant  is  months  old  ( 1  month,  3  ounces ;  2 
months,  4  ounces;  3  months,  5  ounces;  etc.).  Exception- 
ally, infants  cannot  take  this  amount  at  each  feeding,  and 
when  vomiting  is  the  result  of  overfeeding,  the  quantity 
can  be  reduced  and  an  extra  meal  substituted. 

After  the  fourth  month  the  average  infant  will  take 
daily  1  quart  of  the  food  mixture. 

When  more  than  1  quart  of  milk  mixture  is  needed  to 
properly  nourish  the  infant,  we  have  reached  the  age 
when  a  mixed  diet  should  be  instituted. 

By  the  sixth  month  four  meals  of  8  ounces  each  of 
milk  mixture  may  be  given,  and  a  fifth  meal  of  broth 
and  vegetables  (see  rules  for  mixed  diet,  p.  155). 

Water  to  be  Added.  In  our  o^vn  experience  we  have 
found  that  a  concentrated  milk  mixture  does  not  disturb 
the  infant's  digestion  when  the  milk  is  boiled  or  alkalin- 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     153 

ized  by  sodium  citrate,  sodium  bicarbonate,  or  lime- 
water.  The  amount  of  water  is  calculated  by  multiplying 
the  number  of  feedings  by  the  amount  of  each  feeding, 
and  subtracting  the  milk  to  be  given. 

Example:  Baby  aged  3  months  should  receive  5  feed- 
ings of  5  ounces  each  (age  in  months  plus  2)  or  a  total 
of  25  ounces  for  the  day.  Subtracting  16.5  ounces  (11 
pounds  body  weight  and  1.5  ounces  of  milk  for  each 
pound)  gives  us  8.5  ounces  as  amount  of  water  to  be 
added. 

Carbohydrates  toi  be  Added.  Having  the  necessary 
amount  of  mElk  and  water,  we  ascertain  the  carbohy- 
drates to  be  added. 

Cane-sugar  answers  our  requirements  for  most  cases. 

Milk-sugar  acts  as  a  laxative  in  many  infants.  Unless 
the  laxative  effect  is  desirable,  it  has  no  advantage. 

Maltose  and  dextrin  compounds  are  acceptable  to  the 
infant's  digestion  in  relatively  larger  quantities.  They 
are  not  as  sweet  as  cane-sugar. 

Because  of  the  high  dextrin  content,  some  of  the  prod- 
ucts on  the  market  (Horlick's  malt  food,  Mead's  dextri- 
maltose)  may  be  constipating.  Others  which  have  a 
higher  maltose  content  (Borcherdt's  dri  malt  soup,  Mel- 
lin's  food,  both  of  which  also  contain  potassium  carbo- 
nate) are  laxative. 

Cane-  and  milk-  sugars  are  added  in  such  quantities 
that  the  final  mixture  contains  3  to  5  per  cent,  of  sugar 
in  addition  to  the  sugar  in  the  cow's  milk.  Cane-sugar 
is  much  sweeter  than  milk-sugar,  and  the  infant  will 
occasionally  refuse  a  mixture  containing  over  3  per  cent, 
of  cane-sugar. 

Starch  may  be  added  to  the  diet  in  quantities  of  1  to 
2  per  cent,  of  the  whole  mixture  in  the  form  of  cereal 


154  INFANT   FEEDING. 

waters.  We  do  not  hesitate  to  add  cereal  water  to  the 
diet  after  the  infant  is  one  month  old,  and  find  it  espe- 
cially valuable  in  those  cases  in  which  Ave  are  feeding  3 
per  cent,  or  more  of  cane-sugar,  and  in  which  the  infant 
takes  a  dislike  to  its  food  because  of  the  intense  sweet- 
ness of  the  mixture. 

Maltose  and  dextrin  compounds  may  be  added  in  quan- 
tities up  to  6  per  cent,  of  the  total  mixture. 

Roughly,  the  following  quantities  of  cane-  or  milk- 
sugar  will  answer  the  carbohydrate  needs  of  the  infant: 

Infants    under    6    pounds — 0.5    ounce    in    twenty-four    hours 

(2700  Gm.— 15  Gm.). 
Infants  6  to   10  pounds — 0.75  to   1,00  ounce  in  twenty-four 

hours  (2700  to  4500  Gm.— 22.5  to  30  Gm.). 
Infants  10  to  14  pounds — l.OO  to  1.25  ounces  in  twenty-four 

hours  (4500  to  6400  Gm.— 30  to  37.5  Gm.). 
Infants  over  14  pounds — 1.5  ounce  in  twenty-four  hours  (over 

6400  Gm.-45  Gm.). 

To  Break  the  Curd  to  Assist  Digestion  of  Cow's 
Milk.  Many  infants  can  digest  raw  cow's  milk.  When 
not  well  taken,  the  tendency  to  formation  of  large  protein 
curds  is  relieved  by  boiling  the  milk  from  two  to  three 
minutes  over  the  flame,  or,  better,  by  putting  in  a  double 
boiler  and  heating  until  the  water  in  the  outer  vessel 
boils  eight  minutes.  Although  the  curd  is  less  finely 
divided  by  the  use  of  the  double  boiler,  as  compared  with 
boiling  on  the  direct  flame,  it  answers  the  purpose  of 
most  infants,  and  causes  fewer  changes  in  the  milk. 

Addition  of  sodium  citrate  to  the  milk  mixtures  also 
prevents  formation  of  hard  protein  curds.  Bosworth  and 
\''an  Slyke  have  shown  that  increasing  amounts  of  sodium 
citrate  added  to  the  milk  increases  the  coagulation  time 
up  to  the  point  when  1.7  grains  (0.1  Gm.)  per  ounce  (30 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     155 

mils)  is  added,  after  which  the  milk  does  not  coagulate 
at  all.  Sodium  which  is  added  replaces  some  of  tlie  cal- 
cium in  the  caseinate,  and  forms  sodium  caseinate  of  cal- 
cium-sodium caseinate,  and  when  rennin  is  added  this 
double  salt  is  changed  to  calcium-sodium-paracaseinate, 
which  in  the  presence  of  sufficient  quantity  of  sodium 
does  not  curdle.  Sodium  citrate  may  be  prescribed  either 
in  5-grain  tablets,  adding  approximately  1  grain  for  each 
ounce  of  milk  in  the  mixture,  or  a  prescription  may  be 
written  in  such  form  that  each  teaspoonful  will  contain 
sufficient  sodium  citrate  for  the  day's  food. 

When  lime-water  is  added  to  cow's  milk  until  it  is 
neutral  or  faintly  alkaline  to  phenolphthalein,  a  basic  cal- 
cium casein  is  formed  which  is  not  acted  upon  by  rennet, 
and  will  not  form  a  curd,  even  in  the  presence  of  lime 
salts  (Van  Slyke).  Casein  is  not  coagulated  by  rennin 
when  the  solution  is  alkaline.  When  a  sufficient  amount 
of  an  alkali  is  given,  the  milk  mixture  remains  neutral 
or  alkaline  in  the  stomach,  even  after  the  stomach  has 
secreted  acid,  and  large  protein  curds  do  not  form  then. 
Lime-water  is  commonly  used  in  amounts  equaling  5  per 
cent,  of  the  milk  in  the  mixture  (1  ounce  to  20  ounces 
of  milk). 

Not  infrequently  we  have  found  the  adding  of  citrate 
of  soda  or  lime-water  to  boiled  milk  of  advantage  in  the 
difficult  feeding  cases,  and  in  the  presence  of  vomiting. 

Mixed  Diet  for  Young  Infants.  As  early  as  the 
second  or  third  month,  1  or  2  teaspoonfuls  of  orange 
juice  may  be  given  daily.  This  in  part  at  least  counter- 
acts the  effect  of  boiling.  Start  with  5  drops  diluted  with 
water,  twice  daily,  and  increase  gradually. 

Fifth  month,  a  little  well  cooked  cereal  may  be  added 
to  one  of  the  meals  (begin  with  1  teaspoonful),  adding 


156  INFANT   FEEDING. 

part  of  the  bottle  of  milk  to  it,  the  meal  being  finished 
by  the  remainder  of  the  bottle. 

At  sixth  month,  infants  readily  take  a  broth  and  vege- 
table meal  as  a  substitute  for  one  of  the  milk  feedings,  in 
the  form  of  a  vegetable  and  meat  soup.  Begin  with  1 
ounce,  and  follow  by  a  second  bottle  containing  the  milk 
mixture  with  1  ounce  less  than  full  feeding.  Gradually 
replace  an  entire  milk  feeding. 

Ninth  month,  a  vegetable  soup  or  a  clear  broth 
(chicken,  lamb,  or  veal),  and  toast  or  zwieback  crumbs, 
with  an  additional  portion  of  stewed  fruits  (apples, 
prunes)  or  a  strained  vegetable  (spinach,  carrots,  or  tur- 
nips). The  broth  is  usually  given  in  the  same  quantity 
as  the  bottle,  if  given  alone,  or  somewhat  less  if  either 
the  tablespoon  of  vegetable  or  fruit  is  given  in  addition. 

Caloric  Values  of  Foods. 

Amount  Cal. 

Apple  sauce  1  ounce   30 

Bacon   (slice)    %  ounce  30 

Bread    average  slice,  33  Gm 80 

Butter 1  pate  (M  ounce)    80 

Cereal    (cooked)    1     heaping     tablespoonful 

(1  ounce)   50 

Carrots    (cooked)    1  ounce  13 

Crackers       (soda      or 

Graham)    1  ounce  100 

Cream  (16  per  cent.)    ....  1  ounce   54 

Custard  1  ounce   60 

Egg  1    (1.5  ounces)    80 

Egg  (white)    1  30 

Egg   (yolk)    1   50 

Gelatin   1  ounce  50 

Malt  extract    1  ounce!  89 

Meat   1  ounce  50  to  70 

Milk   (whole)    1  pint  • 350 

Milk   (whole)    1  ounce 21 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     157 

Amount  Cal. 

Potato   (whole)    1  medium  sized   90 

Potato   (mashed)    1  heaping  tablespoonf ul 70 

Rice   (boiled)    1  tablespoonful   60 

Soup    (vegetable)    1  ounce  ".  •  15 

Soup    (chicken)    1  ounce  8 

Toast average  slice  80 

Vegetables     (peas,    beans, 

carrots)    1  heaping  tablespoonful 30 

Vegetable     (cooked    spin- 
ach)     1  heaping  tablespoonful 16 

These  caloric  values  are  approximate  for  the  most  part, 
but  are  sufficiently  accurate  for  practical  purposes.  Thus 
the  caloric  value  of  a  particular  menu  can  be  easily 
figured. 

Feeding  Example  No.  1.  Infant  age  three  months 
should  weigh '11  pounds  (average  birth-weight  7  pounds, 
plus  4  pounds,  representing  a  gain  of  5  ounces  weekly  for 
thirteen  weeks).  Estimating  1.5  ounces  of  milk  per 
pound  body  weight,  give  16.5  ounces  of  milk  (346  cal- 
ories). Now,  figuring  that  the  infant  should  receive  25 
ounces  of  food  daily,  5  ounces  at  each  feeding  (age  in 
months  plus  2  ounces)  for  5  feedings,  and  adding  4  per 
cent,  cane-sugar,  or  1  ounce  (120  calories),  a  total  of  466 
calories,  or  about  42  calories  to  the  pound  body  weight. 
To  this  8.5  ounces  of  water  should  be  added  to  make  the 
total  mixture  25  ounces. 

For  practical  purposes  the  cow's  milk  may  be  con- 
sidered as  averaging : 

Proteins   3.5  per  cent. 

Fat    4.0    "       '' 

Carbohydrates    4.0 

Thus,  in  the  milk  mixture  in  feeding  example  No.  1 
ordered  for  a  3-months-old  infant,  weighing  11  pounds, 
we  have  42  calories  per  pound,  and  we  will  now  calculate 


158  INFANT   FEEDING. 

the  percentages  of  the  various  ingredients  in  the  mixture, 
and  the  grams  of  each  ingredient  per  pound  body  weight. 


Milk,      16.5  ozs.  =  495  mils 
Water,     8.5    "  =255    " 
Sugar,      1.0  oz.  =   30  Gm. 


Protein 

uaroo- 
Fat    hydrate 

Salts 

Cal. 

.  17.3 

19.8      19.8 

3.46  Gm. 
(I 

346 



....      30.0 

a 

120 

Total  mix- 
ture, 25.0  ozs.  =750  mils   ...  17.3       19.8  49.8  3.46  Gm.      466 

2.3        2.64  6.6  0.46  per  cent. 

For  each  pound  body  weight  .     1.575     1.8  4.5  0.31  Gm.        42 

We  thus  find  that  the  infant  fed  on  the  prescribed  diet 
receives  25  ounces  of  the  mixture  containing 

Protein    1.575  Gm.  per  pound  body  weight 

Fat   1.8         "       "         "  -  '    .    " 

Sugar    4.5         ^       " 

the  mixture  containing 

Protein   2.3     per  cent. 

Fat    2.64     " 

Sugar    6.6      "       " 

and  42  calories  per  pound  of  body  weight,  all  of  which 
may  be  considered  as  a  safe  minimum.  The  mixture  may 
readily  be  strengthened  to  meet  indications  for  more  fat 
and  protein  by  the  addition  of  milk,  and  more  carbohy- 
drate by  the  addition  of  flour  and  sugar. 

Feeding  Example  No.  2.  Child  age  eight  months 
should  weigh  17.25  pounds  (average  birth- weight,  7 
pounds)  which  should  be  doubled  in  the  first  five  months 
(14  pounds),  plus  a  gain  of  4  ounces  a  week  for  the  re- 
maining thirteen  weeks  (3.25  pounds).  The  following 
mixture  will  be  prepared:  1.5  ounces  of  milk  per  pound 
body  weight  equals  26  ounces  (546  calories)  ;  water  to 
make  one   quart,   equals   6   ounces;   sugar,   3   per  cent.. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     159 

equals  1  ounce  (120  calories)  ;  starch,  1  per  cent.,  equals 
0.3  ounces  (30  calories)  ;  the  total  being  696  calories,  or 
approximately  40  calories  per  pound.  This  is  to  be  fed  in 
four  feedings  of  8  ounces  each,  and  the  fifth  may  be  re- 
placed by  a  soup  and  vegetable  meal.  A  small  cereal 
feeding  (1  tablespoonful)  can  also  be  given  with  1  or  2 
of  the  bottles,  pouring  part  of  the  bottle  of  milk  over  it, 
and  finishing  the  meal  on  the  remainder  of  the  bottle. 
(See  also  Mixed  Diet.) 


Milk,      26.0  ozs.  =  780  mils  . 

Protein 

..  27.3 

Fat 

31.2 

Carbo- 
hydrate 

31.2 

Salts 
5.46  Gm. 

Cal. 

546 

Water,     6.0    "  =180     "      . 

•  •  •  > 

•  .  •  « 

*  •  .  • 

(I 

•  •  • 

Sugar,     1.0  oz.  =  30  Gm.  . 



•  .  .  • 

30.0 

•  •  .  . 

K 

120 

Starch,     0.3   "    =     9    "      . 



•  •  «  • 

9.0 

•  •  •  • 

ii 

30 

Vegetable 

soup,     8.0   "    =240  mils    , 

...    2.0 

4.5 

8.0 

2.4 

it 

144 

Cereal,  one  heaping  tablespoon- 
ful,       1.0  oz.  =  30  Gm 15.0       ....     "  50 


Total  mixture  29.3      35.7      93.2      7.86  Gm.      890 

For  each  pound  body  weight  .     1.7        2.1        5.5      0.46    "  52 

Further  needs  of  the  individual  case  can  be  supplied 
by  concentrating  the  milk  until  whole  milk  is  given,  the 
carbohydrates  in  the  mixture  being  gradually  decreased 
and  given  in  another  form,  as  gruel,  custard,  etc. 

Artificial  Feeding  During  the  First  Weeks  of  Life. 
The  rules  as  given  for  infant  feeding  are  hardly  appli- 
cable for  feeding  during  the  first  one  or  two  to  three 
weeks  of  the  infant's  life.  The  infant's  first  feedings 
should  consist  of  higher  dilutions  of  either  whole  or  skim 
milk,  should  be  boiled,  and  sugar  added  in  smaller  per- 
centages than  suggested  for  the  older  infants.  Such  mix- 
tures must  of  necessity  show  a  lower  caloric  value  than 


160  \  INFANT   FEEDING. 

will  meet  the  infant's  needs  for  growth  and  development, 
but,  as  suggested,  the  mixture  for  the  newborn  should  be 
composed  of  weak  formulae,  and  increased  according 
to  the  infant's  tolerance.  The  following  table  of  mixture 
will  act  as  an  outline  for  average  cases : 

Diet  for  Newborn  Infants  During  the  First  Four 
Weeks  of  Life. 

1st  48    3-4       5-6       7-8-9  10-11-12  13-14     3d       4tli 


Milk  (whole),  ozs.  . 

hours  days 

days 

days 
3 

days 
4 

days 
6 

week  week 

8       11 

Milk   (skim),  ozs.   . . 

. . 

6 

8 

5 

4 

4 

2      ... 

Sugar  (cane),  dr.  . . 

..      1 

1 

2 

2 

2 

3 

4         6 

Water  (boiled),  ozs. 

..   16 

10 

8 

8 

8 

8 

8       10 

Calories  in  mixture 

..   15 

81 

118 

148 

158 

215 

250     321 

Feedings : 

Amount  in  ozs.    . . 

..     1 

1 

1.5 

1.5 

2 

2 

2.5      3 

Number  daily  .... 

..     7 

7 

7 

7 

7 

7 

7        7 

Intervals  in  hours 

..     3 

3 

3 

3 

3 

3 

3         3 

The  above  mixtures  should  be  boiled  for  three  minutes 
over  the  direct  flame  or  in  a  double  boiler.  If  the  latter 
is  used,  the  water  in  the  outer  vessel  should  be  boiling  for 
eight  minutes.  Add  boiled  water  to  make  up  the  original 
quantity. 

Method  of  Feeding  a  Baby  from  the  Bottle.  Babies 
should  be  fed  while  they  are  lying  on  their  beds,  the 
upper  part  of  the  body  being  somewhat  elevated  by  means 
of  a  pillow  of  proper  thickness.  The  baby  should  be 
turned  slightly  on  the  right  side,  as  it  has  been  found  that 
the  stomach  empties  itself  sooner  in  that  position. 

The  bottle  should  always  be  held  by  the  nurse  or  at- 
tendant, until  it  is  empty.  From  fifteen  to  twenty  minutes 
should  be  occupied  with  the  meal. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     161 

Do  the  above  rules  furnish  mixtures  of  a  quality  and 
quantity  proper  to  meet  the  infant's  needs?  If  proper 
mixtures  they  should 

(1)  Contain  approximately 

Protein    1.5  to  2.0  Gm.  for  each  pound  of  body  weight 

Fat    1.5   "  2.0     " 

Carbohydrates   ..  4.0  "  6.0     "       "       "  "        "       " 

(2)  Calories   per   pound   body   weight   for   normal 

infant : 

Under  2  months  of  age   30  to  45  calories 

Over  2  months  of  age  45    "   55 

(3)  Percentages  in  the  mixtures. 

It  is  well  to  know  the  percentages  of  the  various  ingre- 
dients in  the  diet,  as  they  will  assist  in  the  proper  inter- 
pretation as  to  the  etiology  of  food  disturbances. 

Fat.  Infants,  according  tO'  their  age,  under  normal 
conditions,  digest  from  2  to  3.5  per  cent,  of  fat.  Some 
infants  digest  fat  badly,  consequently  in  some  cases  it  is 
necessary  to  give  skim  milk. 

Proteins.  In  the  average  feeding  mixture  for  in- 
fants under  10  months,  2  to  3  per  cent,  of  proteins  are 
well  taken. 

Carbohydrates.  They  should,,  as  a  rule,  not  exceed 
6  to  7  per  cent.,  the  average  amount  in  human  milk,  in- 
cluding the  sugar  contained  in  the  milk  before  its  modi- 
fication. 

Summary. 

I.  Preparation  of  the  mixture. 

1.  Calculate  the  baby's  normal  weight. 

2.  Calculate  the  amount  of  cow's  milk  to  be  used  in  the 

preparation  of  the  mixture,  taking  1.5  ounces  of  cow's 

11 


162  INFANT   FEEDING. 

milk  per  pound  of  normal  body  weight  at  that  age,  which 
is  a  safe  minimum  for  a  healthy  infant. 

3.  Calculate  the  total  daily  amount  of  the  mixture  by 
multiplying  the  amount  of  each  feeding  (age  in  months 
plus  2  ounces)  by  the  number  of  feedings. 

4.  Add  water  to  make  the  mixture  up  to  this  total 
amount. 

5.  Add  3  to  5  per  cent,  of  sugar,  and  later  1  per  cent, 
of  starch. 

6.  Make  the  curd  more  digestible  by  boiling  or  alkalin- 
izing  the  mixture. 

II.  Checks  on  the  above  mixture. 

1.  Number  of  grams  per  pound  body  weight  of  each 
food  ingredient  in  the  mixture. 

2.  Percentage  of  each  ingredient  in  the  mixture. 

3.  Total  caloric  value  of  mixture  and  caloric  value  per 
pound  body  weight. 

III.  Remember  that — 

1.  Orange  juice  or  codliver  oil  additions  to  the  diet 
should  be  started  by  the  second  or  the  third  month. 

2.  When  more  than  1  quart  of  milk  mixture  is  needed 
to  properly  nourish  the  infant,  the  age  is  reached  when 
a  mixed  diet  should  be  instituted. 

3.  These  amounts  are  relative,  and  must  be  increased 
or  decreased  according  to  the  infant's  progress  and  in- 
dividual needs,  the  above  rules  furnishing  a  safe  minimum 
for  a  healthy  infant. 

4.  The  above  amounts  are  usually  insufficient  for  the 
underfed  infant  after  it  has  become  accustomed  to  the 
diet.  Frequently  it  is  necessary  to  approximate  the  re- 
quirements of  a  normal  baby  of  that  age. 

5.  Premature  and  underfed  infants  must  at  first  be  fed 
smaller  amounts. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.     163 

6.  The  food  formula  of  a  baby  clinically  healthy  and 
making  a  satisfactory  gain  in  weight  should  not  be 
changed  without  a  well-defined  indication. 

Explanatory  Note.  For  practical  purposes  we  have  used 
pounds  for  weight,  and  ounces  for  measuring  fluids,  because  of 
the  common  use  in  the  home  of  avoirdupois  scales,  and  bottle 
and  measuring  glass  graduated  in  ounces.  We  have  also  calcu- 
lated 1  oz.  =  30  Gm.,  and  2.2  lbs.  =  1  Kg. 


CHAPTER    V. 

FEEDING  IN  LATE  INFANCY  AND  EARLY 
CHILDHOOD. 

Feeding  During  the  Last  Quarter  of  the  First  Year. 
The  following  diet  list  will  serve  as  an  example  for  feed- 
ing during  this  period : 

Nine  to  twelve  months  diet. 

6.00  A.M.  Milk  mixture,  8  ounces.  Milk,  6  ounces;  water, 
2  ounces;  sugar,  2  level  teaspoonfuls. 

8.30  A.M.  Orange  or  prune  juice,  ^  to  1  tablespoonful  (0.25 
to  0.5  02.).  If  preferable,  this  may  be  given 
with  the  10  a.m.  or  2  p.m.  meal. 

10.00  a.m.     Milk  mixture,  8  ounces.    Cereal  (farina,  oatmeal, 
etc.),  1  to  2  tablespoonfuls. 

2.00  p.m.  Vegetable  soup  or  a  clear  broth  (chicken,  lamb 
or  veal),  with  an  additional  portion  of  a 
strained  vegetable  (spinach,  carrots,  potatoes, 
etc.).  Vegetables  can  be  started  by  the  ninth 
month.  The  broth  is  usually  given  in  the  same 
quantity  as  the  bottle,  if  given  alone,  or  some- 
what less  if  a  vegetable  is  given  in  addition. 
When  starting  the  soup  feeding,  first  replace 
1  ounce  of  the  2  p.m.  bottle  by  1  ounce  of  soup 
in  another  bottle;  then  give  7  ounces  of  the 
milk  mixture.  Gradually  increase  soup  and 
diminish  milk  until  an  entire  bottle  of  milk  iz 
replaced  by  soup.  Gradually  cut  water  and 
sugar  out  of  the  milk  mixture  until  full  milk 
is  given  by  the  tenth  or  eleventh  month. 

6.00  p.m.  Milk  mixture,  8  ounces,  and  bread,  zwieback 
crumbs  or  cereal. 

10.00  P.M.     Milk  mixture,  8  ounces,  if  needed. 

(164) 


FEEDING  IN  INFANCY  AND  CHILDHOOD.        165 

A  slice  of  crisp  bacon  may  be  given  to  advantage  dur- 
ing the  eleventh  and  the  twelfth  months,  probably  best 
with  the  mid-morning  meal. 

Four  feedings  a  day  are  usually  sufficient  during  the 
early  part  of  the  second  year.  In  such  a  diet  the  fruit 
juices  which  may  be  given  once  or  twice  a  day  should 
not  be  considered  as  meals,  and  may  be  given  b^ween 
the  regular  feedings.  Whole  milk  is  now  fed,  and  should 
not  exceed  1  quart  daily.  The  sugar  and  water  are  de- 
creased gradually. 

Twelve  to  fourteen  months  diet. 

6.00  A.M.    Milk,  8  ounces. 

8.30  A.M.     Orange  juice,  prune  juice,  or  apple  sauce  (1  oz.) 
If  preferred,  this  may  be  given  with  the  10  a.m. 
or  2  p.m.  meal. 
10.00  a.m.     Milk,  8  ounces,  and  cereal  (farina,  oatmeal,  etc.) 
1  or  2  tablespoonfuls,  slice  of  crisp  bacon. 

2.00  P.M.  Vegetable  or  cream  soup  and  zwieback,  toast,  etc., 
or  a  clear  broth  (chicken,  lamb  or  veal),  with 
an  additional  portion  of  1  tablespoonful  of  a 
strained  vegetable  (spinach,  carrots,  potatoes, 
etc.).  The  broth  is  usually  given  in  the  same 
quantity  as  the  bottle,  if  given  alone,  but  some- 
what less  if  a  vegetable  is  given  in  addition.  A 
little  scraped  beef  or  beef  juice  may  occasion- 
ally be  added  to  the  vegetable. 

6.00  P.M.    Milk,   8  ounces,   and  bread,   zwieback   or  cereal, 

custard  or  pap. 
10.00  P.M.     Milk,  8  ounces,  if  needed. 

Fourteen  to  eighteen  months  diet. 

6.00  A.M.     Milk  8  to  10  ounces 

8.30  A.M.  Fruit  juice  (orange  juice,  prune  juice,  or  apple 
sauce)  1  to  2  ounces. 


166  INFANT   FEEDING. 

10,00  A.M.  Cereal,  2  to  3  tablespoonfuls,  with  2  ounces  of 
milk  or  cream,  followed  by  6  to  8  ounces. of 
milk.  Toast,  zwieback,  crackers,  or  wafers 
may  be  alternated  with  bacon. 
2.00  P.M.  (1)  Vegetable  or  cream  soup  and  zwieback  or 
toast,  or  (2)  a  clear  brotli  (chicken,  lamb  or 
veal),  with  an  additional  portion  of  one  table- 
spoonful  of  a  strained  vegetable  (spinach,  car- 
rots, potatoes,  etc.).  The  broth  is  usually  given 
in  the  same  quantity  as  the  bottle,  if  given 
alone,  but  somewhat  less  if  the  vegetable  is 
given  in  addition.  Part  or  whole  of  a  coddled 
egg  with  toast,  zwieback  or  cracker  crumbs  can 
now  be  added  to  the  above  soup  and  vegetable 
meal. 

Thei  egg  may  be  alternated  with  beef  juice 
or  scraped  beef. 
6.00  P.M.  Cereal,  2  tablespoonfuls,  farina,  cream  of  wheat, 
oatmeal,  arrowroot,  custard  or  pap,  with  8 
ounces  of  milk.  Part  of  the  milk  may  be  given 
over  the;  cereal,  or  as  bread  and  milk,  or  milk 
toast. 

10.00  P.M.     Milk,  8  toi  10  ounces.     (Can  usually  be  left  out 
by  this  time.) 

Eighteen  months  to  three  years. 

7.00  A.M.  Stewed  fruit  or  orange  juice ;  cereal ;  crisp  bacon, 
alternate  with  soft  boiled  or  poached  egg; 
Bread  and  butter  or  toast ;  milk  or  weak  cocoa. 
12  or  1p.m.  (1)  Broth:  meat  or  vegetable  soup  thickened 
with  cereal.  (2)  Meat :  lamb  chops,  scraped 
beef,  chicken  or  beef  juice.  (3)  Vegetable: 
baked  or  mashed  potatoes;  strained  spinach, 
carrots,  turnips  or  celery.  (4)  Dessert :  gela- 
tine, custard,  cornstarch  or  rice-pudding,  or 
other  simple  dessert. 

6.00  P.M.  Cereal  and  bread  or  cracker,  with  milk.  Baked 
apple,  apple  sauce  or  other  stewed  fruit. 


FEEDING  IN  INFANCY  AND  CHILDHOOD.       167 

Other  Foods  Permitted  at  Three  Years. 

Meats.  Broiled  or  boiled  fish,  roast  or  stewed  poultry, 
raw  or  stewed  oysters,  broiled  beefsteak,  roast  or  broiled 
beef  or  mutton — all  in  moderate  quantities. 

Eggs.    Soft  boiled,  poached  or  scrambled,  1  or  2  daily. 

Cereals  and  Breads.  Oatmeal,  hominy  grits,  wheaten 
grits,  cornmeal,  barley,  rice,  macaroni,  etc.  Light  and  not 
too  fresh  wheat  and  Graham  bread,  toast,  zwieback,  plain 
unsweetened  biscuit. 

Soups.  Plain  soup  and  broth  of  nearly  every  kind, 
preferably  vegetable  broth. 

Vegetables.  White  potatoes,  boiled  onions,  spinach, 
carrots,  peas,  asparagus  (except  the  hard  part),  stewed 
celery,  young  beets,  arrowroot,  tapioca,  sago. 

Fruits.  Nearly  all,  if  stewed  and  sweetened.  Of  raw 
fruits,  peaches  are  the  best;  pears,  grapes  freed  from 
seeds,  oranges. 

Desserts.  Light  puddings,  as  rice  pudding  without 
raisins,  bread  pudding,  plain  custard,  pap,  wine  jelly,  ice 
cream,  junket. 

Foods  to  be  Taken  with  Considerable  Caution. 
Mufifins,  hot  rolls,  sweet  potatoes,  baked  beans,  turnips, 
parsnips,  cabbage,  egg  plant,  stewed  tomatoes,  fresh  corn, 
cherries,  plums,  raw  apples,  huckleberries,  gooseberries, 
currants,  preserved  fruits. 

Foods  to  be  Avoided.  Fried  foods  of  any  kind, 
griddle  cakes,  pork,  sausage,  highly  seasoned  food,  pastry ; 
all  heavy,  doughy,  or  very. sweet  puddings;  unripe,  sour, 
or  wilted  fruit;  bananas,  cucumbers,  nuts,  coffee,  alco- 
holic beverages. 


PART  IV. 

Nutritional  Disturbances  in  Artificially 

Fed  Infants. 


CHAPTER    I. 
MINOR   DISTURBANCES. 

1.  Stationary  Weight. 

Stationary  weight  may  be  reheved  by  the  addition  of : 

(1)  One  to  2  per  cent,  of  starch  (0.25  to  0.5  ounce, 

8  to  15  Gm.),  in  the  form  of  wheat,  barley, 
or  rice  flour,  or  oatmeal  or  barley  water  to 
the  day's  feeding,  or 

(2)  Addition  of  more  sugar,  if  insufficient. 

(3)  One  or  2  per  cent,  of  fat  (cream,  1  to  4  ounces, 

30  to  120  mils),  or 

(4)  Skim  milk. 

The  ingredients  to  be  added  vary  with  the  individual 
requirements  and  the  preceding  diet. 

2.  Vomiting. 

The  young  infant  vomits  easily,  and  without  effort. 
The  weak  sphincter  at  the  cardia  predisposes  to  regurgi- 
tation. Regurgitation  of  only  small  portion  of  the  meal 
is  designated  as  "spitting."  This  latter  symptom  has  be- 
come less  common  since  the  introduction  of  the  longer 
feeding  interval,  which  allows  the  stomach  to  empty  itself 
thoroughly  before  the  next  feeding.  Other  than  too  fre- 
quent feedings,  too  large  an  individual  meal,  and  food 
(168) 


MINOR   DISTURBANCES.  169 

too  rapidly  taken,  are  the  most  common  causes  of  vomit- 
ing. These  conditions  can  easily  be  remedied.  Excessive 
handling  and  abdominal  bands  that  are  too  tight  are  fre- 
quently causes  of  vomiting.  Excessive  feeding  with  fat, 
such  as  is  frequently  seen  in  formulae  made  from  cream 
mixtures  and  top  milk  mixtures,  are  common  causes  of 
vomiting,  and  should  lead  to  reduction  of  the  fat  con- 
tent of  the  food  by  replacing  the  contents  in  part  by 
whole  or  skim  milk.  Excessive  quantities  of  sugar  in  the 
diet  may  also  cause  vomiting.  Vomiting  due  to  the  large 
tough  protein  curd  of  the  raw  milk  can  be  obviated  by 
boiling  or  alkalinizing  the  milk. 

3.  Colic  and  Flatulence. 

Constipation  is  very  frequently  associated  with  colic 
and  flatulence,  disappearing  with  the  institution  of  a 
proper  diet. 

More  commonly  the  habitual  colic,  as  seen  in  the  young 
infant,  may  be  taken  as  an  evidence  of  gastric  or  intes- 
tinal indigestion,  and  may  be  due  to  one  of  several  causes : 
(1)  too  much  milk  at  proper  intervals,  (2)  too  frequent 
feedings,  and  (3)  mixture  too  rich  in  fat,  or  (4)  exces- 
sive in  carbohydrates.  Regurgitation  and  vomiting  are 
commonly  associated,  and  not  infrequently  diarrhea  re- 
sults. By  careful  study  of  the  diet  and  observation  of  the 
stools  the  offending  factor  can  in  most  instances  be 
eliminated. 

Excessive  flatulence  can  frequently  be  eliminated  by 
reduction  or  change  in  the  kind  of  sugar  and  cereal 
gruels. 

A  reduction  in  all  the  elements  of  the  food  may  be 
necessary  temporarily  in  the  presence  of  severe  symptoms. 


170  INFANT   FEEDING. 

Feeding  of  powdered  casein  in  amounts  varying  from  4 
to  8  Gm.,  dissolved  in  30  to  60  mils  of  water,  two  or  three 
times  daily,  will  relieve  colic  in  many  infants,  in  all 
probability  due  to  lessening  of  intestinal  peristalsis. 

Not  infrequently  the  crying  due  to  underfeeding  may 
be  interpreted  as  colic.  Reduction  of  the  diet  of  these 
infants  is  a  source  of  danger.  If  the  stools  are  good,  and 
there  is  no  vomiting,  and  the  baby  is  gaining  in  weight, 
one  should  be  convinced  that  it  is  not  the  cry  of  habit 
before  making  changes  in  the  diet. 

The  constant  solicitude  of  nurses  because  the  baby 
has  "gas  on  the  stomach"  is  unwarranted.  All  bottle-fed 
babies  have  gas  in  the  stomach.  They  swallow  it  with 
their  meals  in  the  form  of  air.  If  the  baby  is  gently 
raised  in  the  sitting  posture  the  gas  will  usually  "come 
up."  This  may  be  done  in  the  middle  of  a  feeding  if  the 
stomach  seems  unusually  distended.  Occasionally  severe 
attacks  of  colic  may  be  relieved  by  a  saline  enema. 

4.  Constipation. 

In  breast-fed  babies,  and  not  infrequently  in  infants  fed 
on  boiled  milk,  we  frequently  find  a  sluggish  rectum, 
which  is  evacuated  to  better  advantage  by  the  use  of 
simple  mechanical  means  than  by  the  use  of  physics.  A 
lubricated  catheter,  a  simple  suppository,  made  from 
glycerin  or  soap,  or  1  to  2  ounces  of  a  saline  enema  or 
sweet  oil  injection  can  be  recommended.  If  properly 
used,  they  are  not  harmful,  nor  do  they  create  bad  habits 
which  are  often  ascribed  to  them.  A  regular  hour  for 
their  use,  with  proper  training,  creates  regular  habits,  and 
in  most  instances  the  condition  improves  to  such  an  ex- 
tent that  they  can  be  discontinued.  Most  infants  can  be 
trained   to   regular   evacuations   by   the   fourth   or  fifth 


MINOR   DISTURBANCES.  171 

month.  The  infant  should  be  well  supported  on  the 
mother's  lap,  over  a  chamber,  which  she  may  hold  be- 
tween her  knees.  This  is  done  to  best  advantage  after  a 
feeding,  and  a  suppository  may  be  used  until  the  infant 
realizes  that  the  operation  is  undertaken  for  a  purpose, 

In  the  presence  of  fat-soap  stool  it  may  be  necessary  to 
reduce  the  whole  milk,  substituting  skim  milk  tempor- 
arily, and  increasing  the  sugar. 

In  the  presence  of  constipation,  where  the  maltose-dex- 
trin compounds  have  been  used,  a  change  to  milk-sugar  or 
cane-sugar,  or  one  of  the  dextrin-maltose  compounds  con- 
taining a  high  percentage  of  maltose  and  potassium  car- 
bonate, is  often  beneficial. 

Occasionally,  the  addition  of  cereal  water  to  the  diet 
is  of  benefit.    The  reverse,  however,  may  be  true. 

When  the  infant  is  old  enough,  constipation  is  best  re- 
lieved by  the  addition  of  vegetable  or  fruit  purees. 

When  the  above  fail,  the  addition  of  1  or  2  teaspoon- 
fuls  of  milk  of  magnesia  (magma  magnesiae,  N.  F.)  to 
the  day's  feeding  answers  well  for  temporary  use,  or  1  or 
2  tablespoonfuls  of  dri  or  liquid  malt  soup  extract  added 
to  the  day's  feeding  acts  equally  well. 

In  infants  where  constipation  is  distressing,  and  other 
dietetic  changes  fail,  a  week  or  two  on  Keller's  malt  soup 
usually  works  wonders. 

Underfed  infants  frequently  suffer  from  constipation. 
Such  stools  (hunger  stools)  are  small,  dark  in  color,  and 
contain  much  mucus,  and  are  associated  with  stationary 
weight.    Increasing  the  diet  relieves  the  constipation. 

5.  Abnormal  Stools. 

(1)  Curds.  Curds  are  seen  as  undig'ested  masses, 
and  may  be  formed  from  fat  or  protein,  or  a  combina- 
tion of  the  two. 


172  INFANT    FEEDING. 

Fat  curds  are  far  more  common  than  protein  curds, 
and  are  usually  seen  as  small,  soft,  whitish  or  yellow 
masses,  either  sprinkled  throughout  the  stools  or  not  in- 
frequently making  up  a  large  part  of  the  stool.  They  are 
usually  intermixed  with  mucus,  which  is  present  in  ex- 
cess. The  chemical  composition  can  easily  be  demon- 
strated by  the  usual  tests  for  fat.  Breast-fed  infants  very 
commonly  show  curds  of  this  type,  and  usually  they  have 
very  little  pathological  significance  in  these  infants. 

Protein  curds  are  far  less  frequent,  and  present  quite 
a  different  appearance.  They  are  also  seen  only  in  the 
presence  of  feeding  with  raw  milk.  They  appear  as 
smooth,  hard  masses,  of  a  yellowish-brown  color,  with 
white  center  when  broken,  and  are  usually  larger  than 
the  fat  curds.  They  are  also  smaller  in  number,  and  may 
be  found  mixed  in  feces  which  otherwise  appears  noniial. 
The  laboratory  test  (ether),  which  causes  the  fat  curds 
to  go  into  solution,  results  in  hardening  and  toughening 
of  the  protein  curds.  This  is  an  easy  method  of  differen- 
tiation.    Such  stools  have  usually  an  offensive  odor. 

Treatment.  The  fat  curds,  if  numerous,  call  for  a 
considerable  reduction  in  the  fat  percentage.  The  protein 
curds,  if  numerous  and  persistent,  should  lead  one  to  re- 
duce the  protein,  at  least  temporarily,  or  also  to  boil- 
ing or  citrating  the  milk,  which  causes  their  disappear- 
ance. In  a  dyspeptic  infant  with  hard  curds  in  the  stools, 
removing  the  sugar  from  the  raw  milk  mixture,  thereby 
lessening  the  frequency  of  stools  and  slowing  peristalsis, 
may  cause  the  hard  curds  to  disappear — that  is,  a  sugar 
diarrhea  that  caused  a  non-digestion  of  the  casein  has 
been  remedied. 

(2)  Loose,  green  stools  with  a  sour  odor  may  be  due  to 
a  high  percentage  of  sugar,  more  commonly  milk-sugar. 


MINOR   DISTURBANCES.  173 

or,  again,  they  may  be  due  to  an  excess  of  fat.  Such 
stools  are  usually  frequent,  and,  if  the  dietetic  error  is 
not  corrected,  may  lead  to  nutritional  disturbances. 
Stools  of  similar  appearance,  which  are  not  infrequently 
seen  in  breast-fed  infants,  have  far  less  significance,  and 
should  not  lead  to  weaning  if  the  child  is  making  at  least 
a  fair  progress.  In  the  artificially  fed,  the  treatment  con- 
sists in  the  careful  study  of  the  diet,  with  removal  of  the 
cause,  when  found. 

(3)  Fat-soap  Stools.  These  are  light-colored,  large, 
dry  stools,  which  do  not  adhere  to  the  napkin,  and  are 
seen  in  feeding  in  which  cream  or  cow's  milk  is  in  excess. 
They  are  described  more  fully  under  Disturbed  Metabolic 
Balance. 

(4)  Starvation  stools  have  already  been  described. 

(5)  Blood  in  Stools.  This  may  be  associated  with 
many  different  conditions,  and  the  character  of  the  stool 
differs  with  the  source  of  the  hemorrhage  into  the  intes- 
tinal tract,  and  may  vary  from  a  tarry  stool  to  one  con- 
taining bright  blood. 

6.  Milk  Idiosyncrasy. 

A  few  infants  show  a  true  idiosyncrasy  to  cow's  milk, 
which  is  overcome  only  with  great  difficulty,  even  when 
the  milk  is  carefully  modified.  The  true  cause  of  this 
condition  is  still  in  dispute.  However,  it  may  be  said 
that  some  of  these  cases  are  undoubtedly  due  to  anaphy- 
laxis. On  the  other  hand,  some  of  them  are  undoubtedly 
not  explained  on  this  basis.  Infants  suffering  from  such 
idiosyncrasy  will  usually  refuse  the  milk,  and  when  it  is 
forced  upon  them  it  results  in  vomiting,  diarrhea,  and 
frequently  an  urticario-erythematous  rash.  Cow's  milk 
feeding  in  these  cases  is  often  associated  with  a  low- 


174  INFANT   FEEDING. 

grade  fever.  The  symptoms  speedily  subside  upon  the 
administration  of  castor  oil  and  the  withdrawal  of  milk. 
This  class  of  cases  offers  great  difficulty  in  feeding  during 
the  first  year  of  life,  as  carbohydrates  must  necessarily 
form  a  considerable  portion  of  their  diet.  Broths,  cooked 
cereals,  and  vegetable  purees  should  be  gradually  added 
to  the  diet  as  soon  as  they  can  be  digested. 


CHAPTER    II. 

GENERAL   CONSIDERATION   OF   NUTRITIONAL 
DISTURBANCES. 

Our  ideas  on  this  subject  have  undergone  considerable 
change  during  the  past  few  years.  Older  authors  viewed 
the  nutritional  disturbances  as  conditions  limited  to  the 
stomach  and  bowel,  and  likened  them  to  similar  condi- 
tions in  the  adult,  with  the  exception  that  more  serious 
results  were  to  be  expected  in  the  infant  because  of  the 
slight  physiological  resistance.  The  infant's  body  is  more 
favorable  to  a  severer  course. 

For  many  years  the  classification  of  Widerhofer,  of  the 
Vienna  school,  first  published  in  1880,  and  based  on  an 
anatomico-pathological  basis  was  the  one  in  general  use. 
These  he  grouped  as  follows : 

1.  Functional  disturbances,  as  acute  and  chronic  dys- 
pepsias. 

2.  Enterocatarrhs,  with  more  or  less  marked  histo- 
logical changes  and  clinical  findings. 

3.  Follicular  enteritis,  with  deep-seated  inflammatory 
and  ulcerative  changes,  especially  in  the  large  intestine. 

4.  Cholera  infantum  (this  latter,  a  severe  type  of  en- 
terocatarrh,  was  classed  as  a  distinct  clinical  entity). 

Clinical  observation  soon  convinces  one  that  the  cases 
do  not  follow  the  distinct  types  in  the  above  classification, 
mixed  and  progressive  types  being  the  rule.  In  many  in- 
stances far-reaching  after-effects  remain,  and,  again,  in 
others  of  the  severest  types  few  if  any  anatomical  lesions 
were  demonstrable  at  autopsy.  Especially  in  young  in- 
fants we  find  marked  and  often  general  disturbances  f ol- 

(175) 


176  INFANT   FEEDING. 

lowing  in  the  wake  of  what  seemingly  were  localized  gas- 
tro-intestinal  lesions,  with  the  result  that  the  systemic  and 
not  the  intestinal  symptoms  were  of  more  serious  import. 
Again,  we  know  that  many  findings  formerly  attributed  to 
invasion  of  bacteria  or  their  toxins  can  now  be  at- 
tributed directly  to  improper  metabolism  of  the  food 
ingested. 

To  avoid  confusion  in  our  discussion  of  this  vast  field 
of  nutritional  disturbances,  we  will  first  consider  the  food 
injuries,  and  speak  only  of  the  infections  incidentally  as 
they  affect  the  former,  and  at  a  later  period  discuss  the 
infections  more  directly. 

Food  Injuries.  The  nomenclature  covering  this  sub- 
ject has  also  changed,  and  we  now^  adopt  the  term 
"Nutritional  Disturbances"  in  place  of  "Gastro-intestinal 
Diseases,"  the  former  covering  the  functional  and  ana- 
tomical disturbances,  as  well  as  the  bacterial  and  food 
traumas.  It  is,  however,  necessary  in  order  to  justify 
the  newer  nomenclature  to.  look  upon  nutritional  disturb- 
ances not  as  localized  in  the  gastro-intestinal  canal,  but 
as  general  affections  involving  the  whole  organism  in  one 
of  the  most  vital  of  its  functions.  The  gastro-intestinal 
symptoms  form  only  a  part  of  the  clinical  picture ;  there- 
fore, in  its  fullest  conception  the  mental  state,  changes 
in  the  temperature,  pulse,  respiration,  etc.,  may  become 
as  important  in  their  interpretation  as  the  diarrhea.  Two 
schools  of  pediatrics  have  given  us  the  nucleus  for  our 
present  view^s  on  nutritional  disturbances  and  their  classi- 
fication— those  of  Czerny  and  Finkelstein.  Czerny's 
work  antedated  that  of  Finkelstein  by  several  years,  and 
he  based  his  classification  on  what  he  considered  injuries 
due  to  overfeeding  with  individual  food  elements.  These 
he  called  ''food  injuries,"  and  described  them  as  due  to 


NUTRITIONAL   DISTURBANCES  177 

fat,  starch,  sugar,  protein,  and  salts,  individually  or  in 
combination,  either  when  given  in  excess,  or  when  given 
to  an  infant  with  lowered  tolerance  for  these  food 
elements. 

Finkelstein  viewed  the  nutritional  disorders  from  a 
broader  standpoint.  He  considered  them  '^as  the  gradual 
development  of  an  increasing  intolerance  for  food" — 
step  by  step,  from  the  mildest  disturbances,  in  which  the 
only  striking  symptom  is  failure  to  gain  in  weight, 
through  the  severer  dyspepsia,  up  to  the  final  stage  of 
intoxication,  when  the  infant  is  in  a  state  of  "metabolic 
bankruptcy"  In  his  classification  we  see  one  increasing 
process,  the  important  factor  of  which  is  found  in  the 
fact  that  the  infant  can  tolerate  less  and  less  food,  until 
finally  any  food  in  any  amount  acts  harmfully.  The 
stages  of  the  various  disorders  under  the  Finkelstein 
classification  must  therefore  necessarily  merge  gradually 
into  one  another,  and  lack  in  definiteness,  and  at  times 
present  a  picture  so  complicated  that  an  exact  diagnosis 
as  to  the  stage  be  temporarily  impossible. 

Etiology  in  General.  Before  entering  upon  a  gen- 
eral discussion,  it  may  be  wise  to  review  some  of  the 
theories  promulgated  for  the  advantages  of  human  over 
cow's  milk  in  infant  feeding.  Biedert  believed  that  the 
decomposition  products  of  protein  digestion  were  the  im- 
portant factors.  This  idea  has  not  been  substantiated 
clinically.  Hamburger  advanced  the  idea  that  the  albu- 
mins foreign  to  the  human  body  contained  in  cow's  milk 
were  important  factors.  Tl"»s  also  has  not  been  proven. 
Czerny  believes  that  the  fat,  and,  again,  the  sugar,  are 
the  important  factors.  L.  F.  Meyer  believes  that  the 
whey  content,  and  more  especially  the  high  salt  content 
of  whey  (0.75  per  cent,  as  compared  with  0.2  per  cent. 

12 


178  INFANT   FEEDING. 

in  human  milk),  predisposed  to  intestinal  injury,  follow- 
ing which  trauma  fats  and  sugars  play  an  important  part. 
Marfan,  Escherich,  Pfaundler,  and  others  believed  that 
specific  protective  bodies  of  unknown  nature  were  con- 
tained in  raw  human  milk,  which  are  of  vast  importance 
as  immunizing  bodies. 

Of  greatest  importance  as  etiological  factors,  as  viewed 
by.  Finkelstein,  are  the  fermentation  products  of  the  fats 
and  carbohydrates,  which  result  in  the  formation  of  the 
lower  fatty  acids  (lactic  acid,  butyric  acid,  etc.).  Protein 
decomposition  is  evidenced  only  by  its  causing  increased 
intestinal  secretion,  a  very  bad  odor  of  the  stool,  and  a 
tendency  to  constipation,  except  in  the  presence  of  large, 
raw  curds,  with  their  tendency  to  mechanical  irritation. 
The  acids  formed  by  fat  and  carbohydrate  metabolism 
when  in  excess  result  in  increased  peristalsis,  increased 
secretion  of  mucus,  etc.  They  may  also  interfere  directly 
with  intestinal  digestion,  or  cause  irritation  of  the  in- 
testinal wall  itself.  In  mild  cases  this  may  result  only  in 
impaired  growth  and  progress,  but  in  the  severer  types 
of  nutritional  disturbances  there  is  breaking  of  the  nor- 
mal relation  between  intestinal  digestion  and  the  paren- 
teral cellular  metabolism,  whereby  the  whole  body  func- 
tion may  be  impaired,  due  to  toxic  products  escaping 
through  the  intestinal  wall  into  the  general  circulation,  or, 
again,  products  necessary  to  normal  growth  may  be  lost 
into  the  intestinal  tract. 

We  know  that  bacteria  and  their  toxic  products,  as 
encountered  in  the  food  administered,  are  less  often 
the  offending  factor  than  formerly  supposed,  and  that 
improper  food  either  quahtatively  or  quantitatively  are 
of  equal  or  greater  importance  in  the  causation  of  nutri- 
tional disturbances.     Food  injuries  can  therefore  be  due 


NUTRITIONAL    DISTURBANCES  1/9 

to :  ( 1 )  underfeeding  by  a  generally  restricted  or  an  im- 
properly balanced  diet,  (2)  overfeeding  with  a  food  of 
proper  or  improper  proportions,  (3)  lessened  tolerance 
for  food. 

1.  Nutritional  Disturbances  Following  Underfeeding. 
We  recognize  two  types:  (1)  qualitative  and  (2)  quanti- 
tative. Sooner  or  later  the  results  are  similar.  The 
former  diets,  qualitatively  wrong,  are  frequently  seen 
where  theoretically  the  caloric  requirements  are  met,  but 
one  or  more  of  the  necessary  food  elements  are  in  excess 
and  the  mixture  short  in  the  required  amounts  of  others. 
An  example  of  this  is  seen  in  feeding  of  carbohydrate- 
rich  foods  as  condensed  milk,  malted  milk,  etc.  When 
the  minimum  requirements  for  growth  and  development, 
at  least  for  both  organic  and  inorganic  salts  are  met  in 
such  a  diet,  the  organism  may  be  able  to  overcome  the 
excess  of  one  ingredient,  but  if  this  is  not  true,  sooner  or 
later  some  grave  complications  will  result.  When  we 
feed  less  than  a  sustaining  diet  of  32  calories  per  pound 
body  weight,  or  70  calories  per  kilogram,  we  soon  have 
the  results  of  a  quantitative  inanition,  with  all  of  its  un- 
desirable results. 

2.  Nutritional  Disturbances  Due  to  Overfeeding.  This 
is  probably  the  most  important  of  all  etiological  factors, 
and  may  be  due  to  a  diet  of  correct  proportions,  but  quan- 
titatively too  great  for  the  individual  case,  or  a  diet  with 
an  excessive  amount  of  one  or  more  constituent  ingred- 
ients. 

To  judge  such  errors  in  diet,  each  individual  infant 
must  be  studied  as  a  distinct  entity. 

3.  Nutritional  Disturbances  Due  to  a  Primary  Lessen- 
ing of  Tolerance  to  Food.  Many  factors  can  cause  such 
a  state  of  affairs : 


180  IXFAXT   FEEDING. 

(a)  Intercurrent  illness,  with  impairment  of  the 
digestive  function.  Bacterial  infections  are 
probably  the  most  common,  and  may  be 
either  general  or  localized  infections. 

(&)  Heat  of  summer,  with  its  depressing  influence 
on  the  organism. 

(c)  Spoiled  milk,  due  either  to  bacteria  contained  or 

their  products. 

(d)  Improper  hygienic  conditions,  with  their  result- 

ing depression. 

General  Symptomatology.  The  varied  symptoma- 
tology of  the  nutritional  disturbances  can  only  be  realized 
when  we  consider  the  numerous  factors  involved  in  the 
process  of  nutrition.  We  must,  therefore,  consider  the 
digestion  of  foods  in,  and  their  absorption  from,  the  in- 
testinal tract,  the  replacing  and  upbuilding  of  the  body 
tissues,  heat  production  and  regulation,  and  the  con- 
trol of  the  functions  of  all  organs  and  tissues.  That 
nutrition  influences  all  of  these  functions  is  evidenced  by 
the  disappearance  of  the  so-called  alimentary  fever,  by 
the  withdrawal  of  food.  This  is  also  true  of  certain 
forms  of  albuminuria.  AVe  also  find  cerebral  and  spinal 
symptoms  as  well  as  cardiac  and  respiratory  changes, 
which  readily  disappear  with  a  corrected  diet. 

By  the  development  of  the  foregoing  symptoms  in  their 
various  phases,  and  under  varied  conditions,  we  can  ex- 
pect the  most  divergent  clinical  pictures.  The  individual 
type  varies  directly  with  the  general  condition  of  the 
infant,  as  well  as  with  the  predominating  dietetic  ele- 
ments. All  infants  suffering  from  nutritional  disturb- 
ances have  a  lessened  food  tolerance.  This  has  a  far- 
reaching  effect,  even  to  the  involvement  of  the  most  re- 


NUTRITIONAL   DISTURBANCES  181 

mote  tissues  and  cells,  which,  again,  is  evidenced  by  a 
general  weakening  of  all  body  functions.  The  end  re- 
sult is  a  paradoxical  reaction  to  food  intake,  which  is  evi- 
denced by  loss  of  weight,  irregularities  in  the  tempera- 
ture curve,  etc.,  on  food  administration  beyond  the  point 
of  tolerance.  These  evidences  of  disturbed  metabolism 
vary  directly  with  the  variety  and  quantity  of  food  intake, 
and  with  the  degree  of  metabolic  disturbance  which. has 
preceded.  A  good  example  of  this  reaction  is  seen  in 
the  following  series  of  cases :  Three  infants  each  are  fed 
30  Gm.  of  sugar  daily,  added  to  their  ordinary  diet.  The 
first  baby,  a  well  one,  gains  in  weight  somewhat  more 
rapidly  than  previously;  the  second  develops  diarrheal 
stools,  a  slight  irregularity  in  the  temperature  curve,  and 
its  weight  remains  stationary;  while  the  third  infant, 
which  was  more  deeply  involved,  develops  a  temperature 
of  101°  and  over,  very  frequent  stools,  and  loses  100  Gm. 
in  weight  in  twenty-four  hours.  Lowered  resistance  is 
not  alone  evidenced  in  the  reaction  to  food,  but  also  are 
lessened  immunity  to  infection,  and  marked  depression  by 
hot  weather.  All  of  these  may  be  followed  by  severe 
systemic  infections,  and  markedly  retarded  convalescence. 

The  normal  healthy  infant  with  a  well-balanced  metab- 
olism reacts  to  food  as  follows : 

1.  An  elastic,  pink  skin,  a  well-developed  panniculus 
adiposus,  well  colored  mucous  membrane.  Its  tissues 
should  feel  firm. 

2.  One  should  expect  certain  muscle  and  bone  develop- 
ment according  to  the  age  of  the  infant. 

3.  A  uniform  rectal  temperature  (98°  to  99°  F.), 
almost  a  monotheria.  Any  considerable  deviation  is 
abnormal. 


182  INFANT   FEEDING. 

4.  It  should  show  a  regular,  steady  gain  in  weight. 

5.  The  bowel  movements  should  be  regular,  and  should 
vary  with  the  food  ingested. 

6.  Its  disposition  should  be  happy,  and  its  nervous 
functions  normal.  It  should  sleep  well,  and  be  satisfied 
with  feedings  at  three-  to  four-  hour  intervals. 

7.  It  should  show  a  wide  tolerance  for  food,  both  as 
to  the  diet  as  a  whole,  and  to  the  individual  food  element. 

8.  Renal,  circulatory,  and  respiratory  functions  should 
be  normal. 

Bearing  in  mind  the  attributes  of  the  healthy  infant, 
we  are  now  in  a  position  to  review  the  factors  leading  to 
and  influencing  our  present  conceptions  of  the*  nutritional 
disturbances,  based  on  an  ascending  series  of  pathological 
stages  in  those  infants  whose  tolerance  for  food  has  been 
overstepped  either  because  of  overfeeding  or  because  of 
diminished  or  abnormal  tolerance  on  the  part  of  the 
baby  itself. 

Classification  of  Nutritional  Disturbances.  The  older 
classification  into  acute  and  chronic  dyspepsia,  entero- 
catarrh,  ileo-colitis,  and  cholera  infantum  must  be  dis- 
carded in  the  light  of  our  new  knowledge,  and  the  whole 
reclassified,  with  the  view  in  mind  that  the  gastric  and 
intestinal  symptoms  are  only  local  evidences  of  a  general 
systemic  involvement,  with  the  clinical  picture  varying  as 
to  the  predominating  food  elements,  the  preceding  gen- 
eral condition  of  the  infant,  and  the  knowledge  that 
changes  are  rapidly  seen  from  one  type  to  another 
through  the  influence  of  various  exogenic  factors. 

For  our  purposes  we  will  combine  the  essentials  of  the 
Czerny  and  Finkelstein  classifications  into  a  working 
basis. 


NUTRITIONAL    DISTURBANCES  183 

Group  I.  Nutritional  disturbances  (food  injuries)  due 
to  overfeeding  (overstepping  the  infant's  food  tolerance). 

(a)  Light  forms,  without  destructive  lesions. 

(1)  Disturbed  metabolic  balance. 

(2)  Dyspepsia. 

(b)  Severe  forms,  with  destructive  lesions  and  gen- 

eral disturbances  of  the  whole  organism. 

(3)  Decomposition. 

(4)  Intoxication. 

The  reaction  to  food  administration  is  the  basis  of  this 
classification,  and  the  degree  of  reaction  depends  directly 
upon  the  preceding  food  injuries.  It  must  also  be  re- 
membered, as  previously  stated,  that  one  form  leads 
rapidly  into  the  next,  if  the  errors  in  the  diet  are  not 
remedied,  or  when  secondary  infections  complicate  the 
picture. 

Group  II.  Nutritional  disturbances  due  to  underfeed- 
ing.    (Insufficient  food.    Inanition.) 

(a)   Quantitative  inanition. 

(Pyloric  stenosis,  pylorospasm,  etc.). 

{b)   Qualitative  inanition. 

(1)  Excessive  starch    (flour)    feeding.     Not  due 

to  excess  of  starch  alone,  but  to  the  lack 
of  other  ingredients  in  the  diet. 

(2)  Scorbutus. 

(3)  Rachitis. 

Group  III.  Secondary  nutritional  disturbances,  follow- 
ing lowered  resistance  and  lessened  food  tolerance,  due  to 


184  INFANT   FEEDING. 

(a)  Heat  J  resulting  in  systemic  depression,  and  often 

associated  with  spoiled  foods  (milk,  etc.). 

(b)  Infections    from    within    the    intestinal    tract 

(enteral). 

(1)  Non-specific  intestinal  infections   (ileocolitis, 

etc.). 

(2)  Specific  intestinal  infections   (typhoid,  para- 

typhoid, dysentery,  etc.). 

(c)  Systemic  infections  (parenteral). 
Otitis,  pyelitis,  pneumonia,  etc. 

Group  IV.  Nutritional  disturbances  due  to  congenital 
debility,  anomalies  or  idiosyncrasies,  with  resulting  ab- 
normal metabolism. 

Food  qualitatively  normal. 

(a)  Exudative  diathesis  (eczema,  etc.). 

(b)  Psychoneuropathic  diathesis. 

(1)  Neuropathic  (strict  sense). 

(2)  Spasmophilia  (tetany,  convulsions,  etc.). 

(3)  Habitual  vomiting. 

(4)  Pylorospasm. 

The  following  scheme  may  be  used  for  classifying  the 
main  types : 

Dis.  Met. 
Balance  Dyspepsia  Decomposition       Intoxication 

Lessened  fat  Lessened   fat  and  Tolerance  lowered  Follows  other 

tolerance.     Food     carbohydrate  to  all  food  forms,   especially 

of  sufficient  tolerance.     Rel.       elements.  when  a  diet  rich 

caloric  value.  excess  of  sugar  in  whey  and 

in  the  food.  sugar  is  not 

corrected. 

Stationary  Stationary  weight  Rapid  loss   of  Rapid  loss  of 

weight.  or  moderate  weight.  weight. 

loss. 

Slight   variations    Moderate  fever.       Subnormal  High  fever. 

in  temperature.  temperature. 


NUTRITIONAL   DISTURBANCES 


185 


Dis.    Met. 

BAXiANCE 


Dyspepsia 


Constipation  with  Diarrhea,   green, 

fat-soap   stools.  mucus,   curds, 
acid. 

Absence   of   acute  Acute 

symptoms,  gastro-intestinal 

general  loss  of  symptoms, 
turgor. 


Sensorium  not 
involved. 


Sensorium  not 
involved. 


Favorable 
reaction  to 
reduction  of  fat 
and  increase  of 
carbohydrates  in 
the  diet. 


Rapid  repair  on 
withdrawal    of 
improper  food. 


Decomposition      Intoxication 


Often  history  of 
diarrhea.  May 
be  constipated. 

Weak,    slow, 
small  pulse. 
Hunger. 
Vomiting. 


Sensorium  not 
involved. 


Starvation 
dangerous,   also 
great  danger  in 
overfeeding. 


Diarrhea,  watery, 
blood,    etc. 


Rapid,    weak, 
small  pulse. 
Rapid,    pauseless 
respiration. 
Hunger. 
"Vomiting. 
Collapse. 
Glycosuria. 
Albuminuria. 
Anuria. 
Leucocytosis. 

Sensorium 
markedly 
involved. 
Nervous 
symptoms 
may    outweigh 
Intestinal 
symptoms. 

Improvement  on 
withdrawal    of 
food. 


CHAPTER    III. 
DISTURBED    METABOLIC    BALANCE. 

Syjiouyms.  Weight  disturbance,  disturbed  balance, 
fat  constipation,  malnutrition,  atrophy  of  moderate  de- 
gree, Bilanz-Stoerung  (Finkelstein),  Milchnaehrschaden 
(Czerny-Keller). 

This  represents  the  mildest  stage  of  nutritional  dis- 
turbances, and  results  from  administration  of  food  be- 
yond the  infant's  limits  of  tolerance,  resulting  in  retarda- 
tion of  development,  both  qualitatively  and  quantitatively, 
however,  without  marked  •  general  symptoms  of  disease. 
This  condition  is  clinically  characterized  by  pallor,  rest- 
lessness, disturbed  sleep,  constipation,  usually  associated 
with  fat-soap  stools,  and  stationary  weight.  Fortunately, 
this  clinical  picture  is  less  frequently  seen  than  formerly, 
when  cream  and  top  milk  mixtures  were  more  extensively 
used. 

Etiology.     It  is  seen  under  a  variety  of  conditions : 

1.  Most  cases  are  caused  by  a  relatively  high  fat  con- 
tent of  the  food,  i.c.^  a  relative  overfeeding  with  whole 
milk,  in  the  presence  of  moderate  amounts  of  carbohy- 
drates ;  therefore  we  have  improper  proportions  of  carbo- 
hydrate and  fat.  In  the  presence  of  excessive  amounts 
of  carbohydrates  we  are  more  likely  to  see  a  dyspepsia. 
Proteins  also  play  an  important  role  in  the  causation  of 
the  clinical  picture  of  this  disease,  in  that  in  the  presence 
of  a  relative  overfeeding  with  proteins  an  alkaline  intes- 
tinal reaction  necessary  to  the  production  of  fat-soap 
stools  is  brought  about.  The  svmptoms  usually  follow  a 
(186) 


DISTURBED    METABOLIC    BALANCE.  187 

period    of    good    progress,    which    ceases   more    or    less 
abruptly. 

2.  Cases  in  which  the  milk  mixture  is  theoretically 
quantitatively  correct,  but  in  which  the  infant  suffers 
from  a  congenital  idiosyncrasy  to  milk.  Many  of  this 
class  of  cases  are  associated  with  exudative  diathesis. 

3.  Following  lowered  food  tolerance  due  to  intercur- 
rent infections,  either  parenteral  or  enteral. 

Artificially  fed  infants  are  almost  exclusively  affected, 
probably  because  of  the  high  carbohydrate  and  low  pro- 
tein content  in  the  breast-fed  infant's  food.  This  con- 
dition was  first  described  by  Czerny  under  the  name  of 
Milchnaehrschaden,  having  been  first  noticed  in  those 
infants  who  received  large  quantities  of  fat  in  the  food. 
This  may  be  due  to  an  absolute  excess  of  fat,  as  seen  in 
the  first  group,  or  a  relative  excess  of  fat,  as  seen  in  the 
second  group  of  infants  having  an  idiosyncrasy  toward 
milk.  Fortunately,  in  these  infants  the  tolerance  for  car- 
bohydrates has  in  most  cases  not  been  reduced,  and  there- 
fore the  fat  in  the  food  can  to  a  great  degree  be  replaced 
by  sugar  and  cereals. 

Pathogenesis.  As  fat-soap  stools  are  so  frequently 
regarded  as  the  basic  symptom  in  the  diagnosis  of  dis- 
turbed metabolic  balance,  we  will  first  emphasize  then- 
significance.  The  fat-soap  stool  must  be  viewed  as  an 
effect,  and  not  as  the  cause,  of  this  intestinal  disturbance. 

The  condition  is  not  a  fat  indigestion,  but  a  disturbance 
in  salt  metabolism,  based  on  a  relative  overfeeding  of  fat 
in  the  presence  of  a  relative  carbohydrate  underfeeding, 
and  enhanced  by  a  relative  excess  of  protein. 

There  is  an  increased  excretion  of  the  alkalies  by  in- 
creased combining  of  alkalies  with  fatty  acids,  and 
through  loss  of  alkalies  by  increased  intestinal  secretion. 


188  INFANT   FEEDING. 

The  alkalies  most  involved  in  the  formation  of  the  fat- 
soap  stools  which  are  so  commonly  seen  in  this  condition 
are  calcium  and  magnesium.  There  is,  however,  also  a 
(iecreased  sodium  and  potassium  retention,  as  evidenced 
more  especially  by  increased  excretion  in  the  urine.  This 
loss  of  calcium  and  magnesium  through  the  stools,  and 
inability  to  retain  sodium  and  potassium,  and  thereby 
secondarily  a  loss  in  water  retention,  soon  leads  to  weight 
loss.  The  fat-soap  stools  as  stated,  contain  an  excess  of 
calcium  and  magnesium  soaps,  and  less  fatty  acids  and 
neutral  fats  than  seen  in  the  normal  stools. 

To  obtain  such  a  stool,  there  must  be  a  strong  alkaline 
reaction  in  the  large  intestine,  and  the  food  elements  of 
the  diet  are  important  factors  in  the  production  of  this 
reaction. 

Fats.  An  excess  of  fats  in  the  food  leads  to  an  ex- 
cess of  fatty  acids  in  the  intestine,  with  a  tendency  to 
the  formation  of  an  acid  reaction  of  the  intestinal  con- 
tent. To  combine  with  these,  alkalies  are  withdrawn 
from  the  body,  if  insufficient  in  the  intestinal  tract. 

Proteins  cause  secretion  of  a  large  quantity  of  intes- 
tinal juice  which  is  alkaline.  This  in  time  tends  to  pro- 
duce an  alkaline  intestinal  reaction,  if  not  counteracted 
by  excessive  fermentation,  the  former  being  favorable  to 
the  formation  of  fat-soap  stools.  In  all  probability  the 
great  calcium  content  of  cow's  milk  (4  to  1),  as  com- 
pared with  breast  milk,  also  offers  another  factor  in  the 
tendency  to  formation  of  calcium  soaps. 

Carbohydrates.  In  the  presence  of  sufficient  ferment- 
able carbohydrates  (disaccharides)  in  the  diet,  the  intes- 
tinal reaction  becomes  acid,  the  products  of  fermentation 
counteracting  the  tendency  to  alkaline  reaction,  and  thus 
preventing  the  formation  of  fat-soap  stools. 


DISTURBED    METABOLIC   BALANCE.  189 

The  withdrawal  of  excessive  amounts  of  alkalies  from 
the  system  disturbs  the  acid-alkaline  equilibrium,  creating 
a  relative  excess  of  acids,  i.e.,  the  formation  of  an  acid- 
osis. This  is  evidenced  by  the  increase  of  the  ammonia 
coefficient  in  the  urine,  i.e.^  the  relation  between  the  am- 
monia and  the  total  nitrogen  products. 

In  disturbed  metabolic  balance  we  find  a  striking  ex- 
ample of  a  paradoxical  reaction,  namely,  increasing  the" 
food  (milk  or  fat)  makes  the  condition  worse,  and  causes 
weight  loss,  diminishing  the  food,  a  return  to  normal, 
and  if  properly  changed,  even  though  lessened,  a  gain  in 
weight. 

The  clinical  picture  is  due  to: 

1.  Excessive  withdrawal  of  salts  from  the  body  tissues, 
due  to  fat  and  protein  overfeeding. 

2.  A  relative  insufficiency  of  carbohydrates. 

The  stools  are  dependent  upon  overfeeding  with  milk, 
with  insufficiency  of  carbohydrates.  To  be  considered 
pathological,  they  must  be  accompanied  by  systemic 
manifestations. 

The  same  stool  may  be  seen  under  normal  conditions 
in  high  protein  and  low  fat  feeding,  more  especially  in 
the  feeding  with  boiled  milk,  as  a  strong  alkaline  intes- 
tinal reaction  is  the  paramount  condition  upon  which 
their  formation  is  dependent. 

Symptoms.  There  is  a  retarding  of  development 
qualitatively  and  quantitatively,  the  infants  frequently  be- 
ing undersized,  without  showing  marked  general  symp- 
toms of  disease. 

1.  Weight.  Notwithstanding  proper  or  even  excessive 
caloric  intake,  there  may  be  no  gain  in  weight,  or  an  irreg- 
ular increase,  however,  under  the  normal.  (Stationary 
weight  or  insufficient  gain  in  the  infant  corresponds  to  a 


190  INFANT   FEEDING. 

loss  in  weight  in  the  adult.  Stationary  weight  in  an  in- 
fant alone  leads  to  the  picture  of  malnutrition  and 
marasmus.) 

2.  Temperature.  Usually  we  find  daily  oscillations 
from  1°  to  2°,  with  a  tendency  toward  subnormal. 

3.  The  child  is  restless. 

4.  Sleep  is  disturbed. 

5.  The  skin  is  pale,  with  loss  of  elasticity  and  turgor. 
Intertrigo  and  eczema  are  frequently  seen. 

6.  Muscles  are  soft  and  flabby. 

7.  Regurgitation  and  vomiting  are  frequent. 

8.  Abdomen  tympanitic. 

9.  Stools.  In  excessive  milk  feeding  the  common  type 
is  the  fat-soap  stool,  which  is  foul-smelling,  dry,  light  in 
color  (gray  to  white),  friable,  and  does  not  stick  to  the 
napkin.  The  pale  color  is  due  to  the  reduction  of  bili- 
rubin to  urobilinogen.  The  odor,  in  part  at  least,  is  due 
to  the  decomposition  of  protein.  In  the  presence  of  ex- 
cessive carbohydrates  this  stool  may  be  lacking,  due  to 
the  presence  of  a  slight  dyspepsia. 

10.  Immunity  is  lessened  with  resulting  furunculosis 
and  susceptibility  to  respiratory,  gastro-intestinal,  and 
genito-urinary  infections. 

11.  Urine  is  usually  ammoniacal,  and  contains  an  ex- 
cess of  sodium  and  potassium  salts. 

Diagnosis  must  be  based  on  the  clinical  pictiu'e  and 
feeding  history,  as  follows:  sufficient  caloric  intake  (100 
calories  per  kilogram),  with  relative  excess  of  fat  and 
protein,  and  insufficiency  of  carbohydrates,  absence  of 
diarrhea,  stationary  weight,  and  lack  of  proper  develop- 
ment, all  in  the  absence  of  any  other  causative  factor. 


DISTURBED    METABOLIC    BALANCE. 


191 


d       "1 

Q  .<   >    iS 

i 

^^ 

.__ 

°^o 

V 

.____L 

O 

5  •• 

!£    to 

a  12 

pi 

III! 

it^ 

\ 

> 

-      -                                       J 

'si  T_ 

0 

•      3;<^ 

f                 5 

•:<n 

L  _      ? 

5 

c 

0 

^<S 

\ 

.._)...' 

°^K 

r 

^ 

? 

o 

.     .o 

0 

jC^ 

:;:z:::::::' 

< 
a 

H 

z 

JcD 

'     N            ? 

_i_ 

c 

j;/M 

f 

t)            1 

1 

-— V        ^^ 

■: 

+  + 

If  ^ 

'^  r 

, 

c 

v. 

c 
c 

/5 

t: 

c 
o 

s'^ 

17                §s 

"■v  \         ? 

=     c 

s«^ 

.H          " 

^^ 

1 

n       ? 

E 

._ 

jC< 

_.V-------iJ 

^N 

—  i^                  s 

C 

%> 

—      < 

^ 

^N 

L- 

>A             5 

^  f 

.     ; 

T 

—      ( 

^ 

■  oi 

5>            5 

1  i 

6   cS 

"■o 

-J     ^. 

=      ( 

- 

JW 

-__    s     \     -^ 

CC 

K 

TS 

../O). 

1         \     "k- 

X 

N 

4 

+ 

^ 

=      ( 

„ 

^  ~ 

-__-_  -___^_,- 

»^rO 

/         '    1 

a 
u 
1- 

D      C 

^ 

s 

— -e-— r    5 

-J               :»            i^ 

'1^ 

.'         r         ^ 

P 

s 

h          o 
1-         q: 

^ 

\           '*          "^  \ 

_i£a 

-—\L  \\  iv 

t 
c 

'i 

a 

a      H 

o 
ooc  § 

L                  K 

s 

___.p\_  'i   1^ 

''lO 

/  ";"~"5. 

c 

c 
<- 

+ 
c 

4 
C 

IT 

H 
□ 

h 

^     < 

i 

IS  n  MIS  ^  Ugn:l  m  >S  M    rf   J 

T 

Q 

NouvoiaaK 

SWOXdWAS                   S 

a 

5t 

is 

y 

a|  2 

zty  - 

o 
> 

ll 
^  s 

S 
Doijn  H 

1 

1 

M  ^  s  ^  ^  ^  = 

;    §    s    ^    s   g   s  § 

O 

§5   S   S    1 

5    S    2    "> 

- 

o 

'i'  'r  '<^'  '4 
1    1,    1   1 

4-        o          ft!  g 
11          |£ 

pstimci 
il!I»nf)  pas 

aoo. 

[TOO 
I 

192  INFANT   FEEDING. 

Underfeeding  and  all  past  illnesses  which  might  retard 
development  must  be  excluded. 

Prognosis  is  very  favorable  in  uncomplicated  cases, 
with  a  properly  instituted  diet.  In  the  average  case  two 
to  three  weeks  is  required  to  overcome  the  constipation, 
and  to  obtain  a  gain  in  weight.  Occasionally  a  severe 
type  is  seen  which  is  difficult  to  overcome,  most  com- 
mon in  infants  with  an  idiosyncrasy  to  cow's  milk. 

Complications.  Because  of  the  lowered  immunity, 
infections  are  common,  especially  of  the  nasopharynx, 
lungs,  middle  ear  and  skin  and  gastro-intestinal  and 
genito-urinary  tract.  Exudative  diathesis  is  not  an  un- 
common associated  condition. 

Sequellae.  Disturbed  metabolic  balance  is  often  the 
forerunner  of  the  more  serious  nutritional  disorders, 
such  as  dyspepsia,  decomposition,  and  intoxication. 
Chronic  constipation  frequently  results,  due  to  the  atony 
of  the  intestinal  wall  and  abdominal  muscles.  Rickets 
frequently  develops  in  these  infants. 

Treatment.  To  institute  a  proper  treatment,  we 
must  remember  that  the  clinical  picture  is  not  dependent 
on  gastro-intestinal  findings  only,  but  also  on  an  abnor- 
mal intermediary  metabolism  (therefore  the  designation 
rvisturbed  Metabohc  Balance),  and  that  fat  overfeeding 
primarily,  and  a  carbohydrate  insufficiency  secondarily, 
are  causative  factors,  and  that  protein  overfeeding  may 
be  an  important  element. 

1.  Diet  with  Human  Milk.  This  is  by  all  means  the 
best  treatment,  especially  in  young  infants.  Weight  in- 
crease may  be  slow  at  first,  probably  due  to  low  salt  and 
protein  content  of  human  milk.  A  loss  of  more  than  6 
to  10  ounces  over  a  period  of  three  or  four  days  is  fre-. 


DISTURBED   METABOLIC    BALANCE.  193 

quently  seen.  More  than  this  should  lead  one  to  suspect 
an  error  in  diagnosis.  This  loss  may  be  due,  as  stated, 
to  stopping  of  a  food  rich  in  proteins  and  salts,  and  sub- 
stituting one  low  in  the  same.  This  stage  is  passed  in 
about  four  days,  when  the  system  adapts  itself  to  the  new 
food  ingredients.  Temperature  and  pulse  do  not  change, 
and  the  stools  assume  a  breast-milk-stool  character.  If 
the  stage  of  reparation  is  slow,  and  the  child  does  not 
gain  in  weight,  the  substitution  of  one  meal  rich  in  pro- 
tein and  salts  daily  will  frequently  help  (buttermilk  or 
skim  milk).  Mother's  milk  also  helps  to  increase  the 
immunity. 

2.  Diet  with  Artificial  Foods.  In  pathogenesis  of  this 
condition  the  milk  fat  plays  the  most  important  role,  and 
this  is  best  counteracted  by  replacing  it  with  well-toler- 
ated carbohydrates.  Protein  tolerance  is  usually  little  im- 
paired, so  that  high  percentage  may  be  retained  in  the 
diet  in  the  presence  of  increased  carbohydrates. 

( 1 )  In  simple  cases  reduce  the  quantity  of  milk  and 

add  carbohydrates  in  the  form  of  sugar  and 
starches. 

(2)  In  severer  cases 

(a)  Malt  soup  (Keller's)  is  exceedingly  valuable. 

Malt  soup  is  indicated  in  the  presence  of 
fat-soap  stools  which  soon  become  pasty 
and  of  mahogany-brown  color ;  the  best  re- 
sults with  malt  soup  are  obtained  in  infants 
from  three  to  six  months  of  age.  After 
six  months  more  milk  than  given  in  the 
original  formula  must  be  added  to  increase 
the  protein  content  of  the  diet. 

(b)  Buttermilk  or  skim  milk  mixtures  (contain- 

ing   two    carbohydrates,    i.e.^    sugar    and 

13 


194  INFANT   FEEDING. 

flour).     The  action  of  both  is  the   same. 
Occasionally  it  is  necessary  in  young  in- 
fants to  reduce  the  sugar  recommended  in 
the  original  formula  (see  Buttermilk  Mix- 
ture, p.  284). 
(c)   Brady's  buttermilk  mixture  No.  1   (p.  284). 
Change  of  the  diet  is   followed  by  better  sleep,  im- 
proved turgor,  skin  becomes  less  pale,  less  variation  in 
temperature.     Stools  change  from  soap  stools  to  (1)  yel- 
low-brown, alkaline'  and  fair  consistency,  when  butter- 
milk  mixtures    are    fed,    (2)    acid,    softer,    mahogany- 
brown  color  when  malt  soup  is  fed. 

These  results  of  treatment  are  due  to  the  fact  that  the 
tolerance  for  carbohydrates  is  high,  and  protein  toler- 
ance is  little  impaired.  Each  case  should  be  watched  to 
see  if  an  excess  of  carbohydrates  is  not  being  given  in 
the  new  diet,  which  is  indicated  by  (a)  restlessness,  (&) 
stopping  of  weight  increase  after  an  early  rise,  (c)  ali- 
mentary fever  (irregular),  (d)  too  frequent  stools.  If 
the  cow's  milk  mixtures  are  not  well  tolerated,  human 
milk  is  indicated. 

The  above  mixtures  should  be  gradually  replaced  by 
ordinary  milk  mixtures  after  two  to  eight  weeks. 

In  infants  over  six  months  of  age  one  of  the  most  con- 
stant and  brilliant  therapeutic  results  follows  the  use 
of  a  limited  amount  of  milk  (boiled  or  citrated)  and  the 
free  administration  of  toast,  zwieback,  rusk,  and  cooked 
cereals  given  in  increasing  quantities  up  to  amounts  that 
will  bring  on  a  steady  gain  of  6  to  8  ounces  a  week.  To 
this  diet  broth  or  vegetable  soup  and  orange  juice  should 
be  added  soon.  In  other  words,  if  a  baby  of  six  or  seven 
months  does  not  gain  on  ordinary  milk  mixtures,  it  should 
be  fed  like  a  normal  baby  of  nine  or  ten  months,  With. 


DISTURBED   METABOLIC    BALANCE.  195 

the  single  exception  that  the  milk  should  be  kept  rather 
low,  or  at  least  given  cautiously,  and  preferably  boiled 
or  citrated,  or  both.  In  many  cases  this  can  be  done 
even  in  the  fifth  month. 


CHAPTER    IV. 

THE    STAGE    OF   DYSPEPSIA. 

Synonyms.  Stadium  dyspepticum,  indigestion,  Zuck- 
ernaehrschaden. 

Etiology.  Dyspepsia  may  develop  either  primarily 
in  a  healthy  child  or  as  a  sequel  of  disturbed  metabolic 
balance,  when  the  insufficiency  of  the  intestine  has  be- 
come such  as  to  make  it  impossible  to  avoid  development 
of  pathological  fermentation.  This  may  be  due  either 
to  absolute  or  relative  overfeeding,  or  because  of  pri- 
mary influence,  which  tends  to  decrease  the  food  toler- 
ance. The  products  of  fermentation  cause  increased 
peristalsis,  which  leads  to  the  chief  symptom  of  dyspep- 
sia, diarrhea. 

The  nlost  important  factors  may  be  enumerated  as 
follows : 

1.  Errors  in  diet  with  milk  of  good  quality:  (a)  over- 
feeding with  diet  of  normal  proportions  (too  frequent 
and  too  much)  ;  (b)  feeding  with  a  diet  of  improper  pro- 
portions (excess  of  sugar,  etc.)  ;  (c)  excess  of  raw  milk, 
with  resulting  mechanical  irritation,  due  to  large,  hard 
protein  curds. 

2.  Extremes  of  temperature,  heat  of  summer  and  cold 
of  winter,  with  resulting  systemic  depression. 

3.  Feeding  with  infected  milk  (decomposition  products 
of  milk  and  bacterial  toxins). 

4.  Infections  of  the  gastro-intestinal  tract  {enteral  in- 
fections) . 

(196) 


THE   STAGE   OF   DYSPEPSIA.  197 

5.  Systemic  infections  (otitis,  pharyngitis,  pyelitis, 
etc.),  associated  constantly  with  a  lessened  tolerance  for 
food   (parenteral  infections). 

6.  Congenital  lowered  tolerance  to  cow's  milk. 

In  practice,  especially  in  young  infants,  frequently  we 
do  not  observe  the  stage  of  disturbed  metabolic  balance, 
because  dyspepsia  develops  directly,  due  to  a  relative  ex- 
cess of  sugar  in  the  food. 

Pathogenesis.    We  will  discuss  in  detail  the  second 
group  of  cases,  those  due  to  feeding  with  a  diet  of  im- 
,  proper  proportions. 

The  symptoms  of  dyspepsia  are  brought  about  by  in- 
creased acid  fermentation,  which  causes  increased  peris- 
talsis, and  increased  intestinal  secretion,  with  resulting 
loss  of  body  fluids.     Pathological  breaking  down  of  car- 
bohydrates (sugars,  flour)  is  to  be  regarded  with  great- 
est probability  as  primary.    It  is  probable  that  the  fat  in 
most  cases  is  involved  only  secondarily,  as  a  result  of  the 
increased     peristalsis,     fermentation,     etc.       The     same 
amount  of  fat  is   commonly  tolerated  perfectly  if  the 
sugar  is  lessened  sufficiently.     It  is  also  probable  that 
the  fat  has  an  unfavorable  influence  on  the  sugar  toler- 
ance.    That  the   decomposition   products   of   casein   do 
damage  to  the  intestines  could  not  be  demonstrated.    On 
the  contrary,  it  was  found  that  by  sufficient  doses   of 
casein  the  pathological  fermentation  could  be  combated, 
and  thus  the  casein  has  a  directly  curative  influence,  as 
seen  in  the  tendency  to  formation  of  fat-soap  stools.    By 
reduction  or  complete  withdrawal  of  carbohydrates  the 
pathological  fermentation  can  in  almost  all  cases  be  de- 
creased, and  also  the  peristalsis,  and  this  seems  to  prove 
that  the   carbohydrates   are  the  primary  cause   of   this 


198  INFANT   FEEDING. 

condition.  The  different  carbohydrates  show  different 
tendency  to  fermentation.  Milk-sugar  ferments  most 
easily,  less  easily  the  cane-sugar,  and  least  the  dextrin- 
maltose  preparations. 

By  clinical  experiments  it  was  found  that  the  toler- 
ance of  even  the  same  intestine  towards  carbohydrates  is 
not  always  the  same,  and  that  it  also  depends  to  a  cer- 
tain extent  upon  the  quality  of  the  fluid  in  which  they 
are  dissolved  or  suspended.  The  same  amount  of  sugar 
given  with  large  quantities  of  whey  produces  much  more 
easily  dyspeptic  symptoms  than  the  same  amount  of  sugar 
administered  in  less  whey  or  in  water.  From  this  it  fol- 
lows that  in  pathogenesis  of  dyspepsia  of  artificially  fed 
infants  the  whey  is  also  of  importance,  this  being  in  all 
probability  due  to  the  quality  and  quantity  of  the  whey 
salts. 

Symptoms.  Dyspepsia  is  characterized  clinically  by 
acute  gastro-intestinal  symptoms,  the  most  marked  of 
which  are  the  stools,  which  are  increased  in  number,  and 
of  an  abnormal  quality.  The  organism  does  not  show 
signs  of  any  deep-seated  general  changes;  weight  loss  is 
moderate  or  the  weight  remains  constant.  Temperature 
is  moderately  increased,  and  repair  is  rapid  with  the 
withdrawal  of  improper  food. 

Several  general  symptoms  are  usually  absent  in  the 
early  stages.  The  mind  is  clear.  The  heart  action  is  not 
rapid.  Respirations  are  not  greatly  increased.  The  baby 
is  restless  and  fretful,  cries  a  great  deal  of  the  time, 
sleeps  brokenly,  and  sucks  its  hands  and  other  objects  as 
if  hungry.  The  face  soon  becomes  drawn,  and  the  tis- 
sues more  or  less  flabby  through  loss  of  body  fluids.  The 
skin  shows  little  change.  Temperature  is  moderately 
increased. 


THE   STAGE   OF   DYSPEPSIA. 


199 


Weight.  The  weight  loss  varies  directly  with  the  loss 
of  body  fluids  through  the  increased  intestinal  peristal- 
sis and  consequent  diarrhea. 


Year1.Q1Q 


^BflRV       DiagnosisJlYSPiESlA^ 


R. 


Case  No — _^ Complications — I^LOJ^l 


%    Age  _fl  J^oriius. 

gj  Weight  LS^DAmDs 
a  I  Condition   Poor 


g      Date^SeJCUSiO 

§    Age  8-^3  MoriTH^ 
£J  Weight  I5lbs6ozi 

2  [  Condition    (^000. 


Fig.  10. — Chart  showing  hospital  record  of  an 
infant  with  dyspepsia. 


Gastro-intestinal  Symptoms.  The  appetite  is  poor. 
The  mucous  membrane  of  the  mouth  is  red,  and  may  be 
the  seat  of  thrush  (due  to  decreased  immunity).    Vomit- 


200       '  INFANT   FEEDING. 

ing  may  be  present,  and  usually  occurs  long  after  feed- 
ing. Volatile  fatty  acids  may  be  detected  in  the  stomach 
content  by  their  odor.  The  abdomen  is  distended,  and 
peristalsis  increased,  and  is  visible  or  can  be  heard  by  aus- 
cultation.    Restlessness  is  marked. 

Stools.  The  clinical  diagnosis  is  usually  made  from 
the  stools.  They  are 'increased  in  frequency,  and  they 
also  differ  from  the  normal.  They  are  thinner,  contain 
more  mucus,  and  are  either  watery  or  hashy.  There  is 
abnormal  odor,  either  that  of  decomposition  or  that  of 
acid  fermentation.  The  reaction  is  variable,  mostly  acid. 
The  color  of  the  stool  is  often  green,  this  being  due  to 
transformation  of  bilirubin  to  biliverdin  by  oxidizing 
ferments. 

The  increased  peristalsis  results  in  impairment  of  ab- 
sorption, which  may  easily  be  determined  by  metabolic 
experiments,  and  also  estimated  by  macroscopic,  micro- 
scopic, and  chemical  examination  of  the  stools. 

Fatty  acids  appear  in  the  stools  in  the  shape  of  white 
or  yellowish  lumps  (milk  curd),  and,  by  addition  of 
strong  acids  and  slight  warming,  fatty  acid  needles  may 
be  crystallized  from  them. 

Neutral  fat  is  present  in  the  form  of  smaller  or  larger 
drops. 

If  flours  are  in  excess,  the  stools  are  frequently  paste- 
like and  foamy.  By  iodine  solutions  the  unchanged 
starches  are  stained  blue,  and  the  erythrodextrin  is 
stained  red. 

Of  especial  interest  has  been  for  some  time  the  ques- 
tion whether  in  stools  undigested  casein  was  found.  The 
yellowish  lumps,  the  so-called  milk-curds,  in  the  hashy 
stools,  seen  even  in  feeding  with  boiled  milk,  have  erron- 
eously been  regarded  as  casein  curds,  which  were  sup- 


THE   STAGE   OF   DYSPEPSIA.  201 

posed  to  escape  digestion  on  account  of  their  being  diffi- 
cult of  digestion.  Today  we  know  positively  that  these 
so-called  "casein  curds"  are  composed  chiefly  of  fatty 
acid  salts  and  bacteria.  Only  in  feeding  with  raw  milk 
frequently  large,  tough,  bean-like  casein  curds  pass 
through  the  intestine  without  being  digested.  Even  in 
the  presence  of  true  casein  curds,  however,  one  must  not 
conclude  that  they  are  the  primary  factors  in  the  patho- 
genesis of  this  nutritional  disturbance  unless  we  are  cer- 
tain that  an  excess  of  raw  milk  has  been  fed. 

Varieties.  First,  the  acute  dyspepsia,  which  begins 
with  a  definite  acute  onset,  usually  in  infants  who  have 
been  previously  well,  and  second,  a  chronic  dyspepsia, 
which  begins  less  acutely,  or  follows  acute  attacks,  and 
which  recurs  even  in  the  presence  of  a  carefully  regu- 
lated diet.  It  soon  becomes  evident  that  in  the  latter 
cases  there  is  a  definite  lessening  of  the  food  tolerance. 

Diagnosis.  The  diagnosis  can  be  made  only  by  a 
careful  consideration  of  the  feeding  history  and  the  clin- 
ical and  functional  symptoms. 

It  is  first  necessary  to  differentiate  dyspepsia  from  the 
milder  forms  of  enteral  and  parenteral  infections.  The 
latter  are  frequently  associated  with  intestinal  irritation. 
One  must  remember  that  the  infections,  especially  in 
young  infants,  are  frequently  associated  with  a  second- 
ary nutritional  disturbance,  and  vice  versa,  that  secondary 
infections  commonly  follow  in  the  wake  of  nutritional 
disturbances.  An  infection  should  be  suspected  when 
the  temperature  remains  high  after  the  withdrawal  or 
reduction  of  the  food  (especially  of  the  carbohydrates), 
and  when  albumin  and  hyaline  casts  appear  in  the  urine, 
and  the  mucus  continues  in  excess  in  the  stools,  present- 
ing the  picture  of  a  secondary  enterocolitis.     If  jnfeQ- 


202  INFANT  FEEDING. 

tions  are  not  recognized,  there  is  a  great  danger  of  con- 
tinuing the  starvation  diet  (which  has  been  inaugurated 
for  the  treatment  of  dyspepsia)  too  long,  and  thereby 
reducing  the  vitahty  of  the  infant  to  the  stage  of  decom- 
position. It  is  also  of  importance  to  note  whether  the 
dyspepsia  is  primary  or  an  acute  exacerbation  in  the 
course  of  a  decomposition,  as  on  this  diiiferentiation  to  a 
great  extent  depends  the  prognosis  and  the  therapy. 
Here,  again,  a  careful  history  is  of  vast  importance,  and 
one  should  carefully  note  the  presence  of  repeated  dys- 
peptic attacks,  with  recurring  fluctuations  in  weight,  the 
occurrence  of  previous  infection,  both  enteral  and  paren- 
teral, as  all  of  these  indicate  a  tendency  to  decomposition. 

Prognosis.  In  infants  previously  health}^  and  with 
a  proper  dietetic  treatment,  the  prognosis  is  good.  Re- 
peated attacks  should  always  be  seriously  considered. 
Dyspepsia  in  very  young  infants  is  always  more  serious 
than  in  the  older  and  better  developed  ones. 

Treatment.  Human  Milk.  The  best  treatment  of 
all  forms  of  dyspepsia  consists  of  feeding  human  milk. 
The  younger  the  infant,  the  more  the  indication  for 
human  milk.  This  is  especially  true  of  infants  under 
two  months  of  age.  In  severe  cases  it  may  be  necessary 
to  place  the  infant  on  a  starvation  diet  for  six  to  twelve 
hours,  and  then  administer  the  breast  milk  in  restricted 
amounts. 

Artificial  Feeding.  In  artificial  feeding  the  treatment 
of  acute  dyspepsia  is  somewhat  different  from  the  treat- 
ment of  chronic  dyspepsia. 

Acute  Forms.  In  the  acute  form,  where  the  child  was 
previously  well  and  its  tolerance  good,  the  simple  unload- 
ing of  the  intestine  may  allow  it  to  resume  its  normal 
function.     The  following  treatment  is  recommended : 


THE    STAGE    OF    DYSPEPSIA.  203 

1.  Starvation  or  Hunger  Diet.  Short  (six  to  twelve 
hours,  rarely  longer)  starvation,  only  liquids  being  ad- 
ministered, tea  with  saccharin  being  the  best  (saccharin, 
1  grain  [0.065  Gm.]  to  1  quart  [1000  mils]).  They 
should  be  given  freely,  up  to  amounts  of  the  total  fluids 
needed.  This  permits  the  stomach  and  the  intestines  to 
empty  themselves,  and  to  assume  their  normal  functions. 
Laxatives  are  usually  not  indicated.  If  temporary  star- 
vation is  inaugurated,  the  intestinal  tract  soon  empties 
itself  of  its  irritating  contents. 

2.  Indifferent  Diet.  During  the  second  day  in  young 
infants,  one-third  whole  milk  (best  boiled  or  citrated) 
plus  two-thirds  thin  oatmeal  gruel,  without  sugar,  may 
be  fed,  such  a  diet  being  low  in  food  value  and  salts. 
Buttermilk  or  skim  milk  may  be  used  in  place  of  the 
whole  milk  in  severe  cases.  The  total  daily  quantity  of 
the  milk  mixture  on  the  second  day  should  not  exceed  6 
to  12  ounces,  divided  into  six  feedings  of  1  to  2  ounces 
each.  To  this,  20  to  25  ounces  of  tea,  plus  saccharin,  may 
be  added,  making  a  total  of  about  1  quart  of  fluid  for  the 
day.  This  will  usually  answer.  Further  treatment  de- 
pends on  the  reaction  to  the  above.  Upon  this  treatment 
the  general  condition  improves,  also  the  disposition,  etc., 
and  the  weight  loss  ceases  in  two  or  three  days.  When 
this  is  not  the  case,  decomposition  or  infection  should  be 
suspected. 

3.  Sustaining  Diet.  Gradually,  and  as  rapidly  as  pos- 
sible, the  food  should  be  increased,  the  increase  to  be 
made  at  least  every  other  day,  in  order  to  limit  the  under- 
feeding to  minimum.  By  the  third  day  the  quantity  of 
the  milk  mixture  should  be  increased,  the  quality  may  be 
left  unchanged,  giving  water  or  tea  to  the  necessary 
quantity  of  fluids  between  the  feedings.    Weight  increase 


204  INFANT   FEEDING. 

should  not  be  expected  because  of  the  low  sugar  content 
and  low  caloric  value  of  the  diet,  but  a  decrease  in  weight 
should  always  be  considered  serious.  The  stools  are  at 
first  small  and  contain  mucus,  later  less  frequent,  and 
often  on  milk  mixtures  without  sugar  there  are  fat-soap 
stools  which  are  a  good  indication. 

4.  Ordinary  Diet.  In  mild  cases,  the  ordinary  milk 
mixtures  proper  for  the  given  infant  may  usually  be  re- 
sumed by  the  end  of  a  week.  In  more  severe  cases,  re- 
turn to  a  full  diet  should  be  slower.  In  these  mixtures, 
the  carbohydrates  should  be  started  with  1  per  cent,  of 
the  whole  mixture,  and  gradually  increased  to  5  per  cent. 
The  carbohydrates  most  suitable  for  this  purpose  are  the 
maltose-dextrin  compounds,  especially  those  with  a  high 
dextrin  content  and  no  potassium  carbonate.  In  older  in- 
fants cereals  in  the  form  of  flour  ball,  barley  flour,  farina, 
zwieback,  can  often  be  added  to  advantage,  as  well  as 
clear  broths.  At  first  there  is  a  rapid  increase  in  weight, 
later  on  a  slower  one. 

Avoid  underfeeding  too  long,  even  if  the  stools  look 
bad,  if  the  temperature  and  weight  curves  improve,  be- 
cause of  the  danger  of  decomposition.  It  should  be  borne 
in  mind,  therefore,  that  it  is  undesirable  to  underfeed  for 
a  long  period,  and  more  especially  dangerous  to  inaugu- 
rate starvation  repeatedly,  or  to  keep  an  infant  for  days 
on  a  starvation  diet,  such  as  cereal  waters  or  very  weak 
milk  mixtures.  It  is  also  necessary  to  know  and  recognize 
the  stools  of  an  underfed  infant  (hunger  stool).  This  is 
greenish-brown  in  color,  composed  chiefly  of  mucus,  and 
small  in  amount,  and  sometimes  frequent.  They  should 
not  be  mistaken  for  the  curd-containing  frequent  stools 
of  dyspepsia,  as  the  former  is  an  indication  for  the  re- 
sumption of  food,  while  the  latter  indicates  starvation, 


THE   STAGE   OF   DYSPEPSIA.  205 

Fats  can  be  added  in  place  of  sugars,  but  this  should  be 
done  with  care.  CodHver  oil  has  given  us  the  best  re- 
sults. It  should  be  given  in  small  quantities  at  first,  be- 
ginning with  1  mil  twice  daily,  and  increased  to  4  mils 
per  dose. 

In  some  infants  the  above-described  treatment  is  un- 
successful. In  one  group  of  these  cases  the  loss  of 
weight  is  not  favorably  influenced,  while  the  stools  im- 
prove; and  in  a  second  group  the  loss  continues  with 
continued  diarrhea.  In  these  cases  there  is  either  infec- 
tion or  they  are  cases  of  grave  nutritional  disturbances  on 
transition  to  decomposition.  It  would  be  a  very  great 
mistake  to  continue  starvation  longer,  with  the  idea  that 
by  giving  the  digestive  tract  longer  rest,  it  may  still  re- 
cover. This  may  kill  the  child.  In  these  cases  treatment 
as  recommended  for  decomposition  or  infection  must  be 
instituted.  Therefore,  it  is  advisable  to  use  routine 
treatment  as  described  above,  and,  if  not  successful,  the 
underfeeding  should  not  be  continued  under  any  circum- 
stances, but  the  treatment  for  decomposition  (described 
later)  or  infection  (see  Infections)  should  at  once  be  in- 
stituted, if  human  milk  is  not  obtainable. 

It  is  in  these  cases  that  Finkelstein's  albumin  milk  is 
indicated.  (See  p.  292,  for  preparation,  and  p.  236,  for 
method  of  administration.) 

Chronic  Cases.  In  treatment  of  chronic  forms  there  is 
no  indication  for  underfeeding.  Since  here  there  is  no 
transitory  weakness,  but  a  chronic  weakness  of  tolerance, 
the  additional  trauma  of  starvation  would  have  an  un- 
favorable influence.  Carbohydrates  are  to  be  reduced 
to  the  amounts  absolutely  necessary  (about  2  to  3  per 
cent),  and  the  less  easily  assimilable  carbohydrates  are  to 
be  replaced  by  those  that  are  more  easily  assimilated 


206  INFANT   FEEDING. 

(maltose-dextrin  mixtures).  If  this  does  not  improve 
the  stools,  then  nursing  on  the  breast  or  albumin  milk 
feeding  is  necessary.  If  both  of  the  latter  are  not  avail- 
able, then  the  quantities  of  foods  should  be  carefully 
measured,  with  the  hope  that  when  the  child  becomes 
older  the  tolerance  will  become  physiologically  increased, 
and  the  condition  thereby  undergo  spontaneous  healing. 

Medicinal  Treatment.  This  is  unnecessary  in  most 
cases.  For  the  treatment  of  irritative  conditions  which 
persist  even  after  the  dyspepsia  proper  (loose  stools  in 
presence  of  gain  in  weight),  astringents  are  of  use. 
Tannigen  or  tannalbin  1  to  5  grains  (0.065  to  0.325  Gm.) 
four  to  five  times  daily  will  answer,  or  calcium  lactate  in 
doses  of  10  to  15  grains  (0.65  to  1  Gm.)  may  be  pre- 
scribed in  a  10  per  cent,  solution  to  be  added  to  each  milk 
feeding. 


CHAPTER    V. 
THE    STAGE    OF   DECOMPOSITION. 

Synonyms:    Marasmus,  atrophy,  pedatrophy. 

The  third  stage  of  impaired  nutrition  in  the  classifica- 
tion of  Finkelstein,  called  by  him  decomposition,  is  recog- 
nized by  him  as  what  has  been  described  in  pediatric 
literature  as  marasmus  or  atrophy.  The  clinical  picture 
may  be  viewed  as  the  end  result  of  repeated  nutritional 
disturbances  or  constitutional  factors.  The  past  history 
is  of  the  utmost  importance,  and  a  careful  search  reyeals 
improper  diets,  with  resulting  disturbance  of  nutrition, 
or  a  nutritional  disturbance  following  enteral  or  paren- 
teral infections,  each  leaving  in  its  wake  evidence  of  im- 
paired nutrition,  until  after  weeks  or  months  we  have 
reached  the  stage  of  deep-seated  tissue  starvation.  The 
chronic  infections,  such  as  syphilis  and  tuberculosis,  may 
also  result  in  a  similar  picture,  but  must  be  differentiated 
to  clear  the  classification  for  therapeutic  purposes. 

During  this  stage  it  becomes  increasingly  difficult  for 
the  infant  to  assimilate  a  sustaining  diet,  with  resulting 
extreme  loss  of  weight,  and  great  lack  of  resistance  of 
the  organism  to  infections  and  other  injurious  external 
influences  (heat,  cold),  this  general  weakening  of  the 
vitality  of  the  infant  being  due  to  perverted  metabolism, 
consisting  of  breaking  down  of  the  body  substance,  and 
change  in  the  composition  of  the  cells  (abnormal  kata- 
bohsm),  and  of  deficient  and  improper  assimilation  of 
the  food  (abnormal  anabolism). 

Etiology.     Disturbed  metabolic  balance  may  be  the 

(207) 


208  INFANT   FEEDING. 

direct  forerunner  of  decomposition,  if  the  dietetic  error 
is  not  corrected ;  likewise  all  factors  leading  to  dyspepsia 
and  intoxication  may  also  be  forerunners  of  decomposi- 
tion. At  what  moment  this  change  takes  place  we  have 
no  means  of  telling,  but  we  know  that  deep-seated  organic 
changes  are  necessary  to  its  development;  these  changes 
which  produce  such  an  intolerance  toward  nourishment 
may  have  developed  previously  to  the  preceding  illness, 
or  during  its  course.  Premature  infants  are  especially 
predisposed,  also  young  infants  with  previous  dietetic 
errors  and  diarrheal  attacks,  also  those  fed  on  a  one- 
sided diet,  excessive  in  carbohydrates,  especially  cereal 
waters,  and  gruels,  as  seen  in  too  long  continued  hunger 
diet.  Especially  to  the  very  young  does  the  statement  as 
to  cereal  waters  and  gruels  apply.  All  of  the  preceding 
reduce  the  tolerance  toward  assimilation  of  a  full  and 
normal  diet.  The  tendency  to  decomposition,  and  there- 
fore to  the  narrowing  of  tlie  nutritional  sphere  increases 
with  each  dyspeptic  attack.  Czerny's  internal  hunger,  or, 
as  he  commonly  calls  it,  ''cell  hunger,"  is  the  cause  of  de- 
composition. The  above  term  is  used  in  contradistinc- 
tion to  hunger  as  usually  thought  of,  which  is  due  to  a 
lack  of  food  to  appease  the  appetite. 

Pathogenesis.  In  the  older  literature  the  terms 
marasmus  and  atrophy  were  used  to  describe  the  clin- 
ical picture  as  presented  by  this  condition.  And  it  was 
assumed  that  destructive  changes  in  the  intestinal  glands 
following  chronic  inflammation,  with  a  secondary  impair- 
ment of  the  functions  of  absorption  and  excretion,  were 
the  underlying  pathological  conditions,  which  resulted  in 
an  inanition.  This,  however,  has  been  found  to  be  erron- 
eous, since  repeatedly  the  intestine  of  the  atrophic  infants 
was  found  to  be  normal. 


THE    STAGE   OF   DECOMPOSITION.  209 

The  great  and  sudden  fluctuations  in  weight  as  seen  in 
this  condition  must  in  the  first  place  be  due  to  loss  of 
water  and  salts,  while  the  disintegration  of  the  body  sub- 
stance, including  the  cells,  furnishes  only  a  smaller  quota 
to  the  loss  of  weight. 

The  researches  of  Czerny  on  metabolism  have  thrown 
considerable  light  on  this  condition.  The  abnormal  split- 
ting of  sugar  and  fats  contained  in  the  food  produces  ex- 
cessive amounts  of  acids  in  the  intestines,  which  results 
in  the  loss  of  alkali  salts,  first,  through  neutralization 
of  the  acids  formed  in  the  intestinal  tract  from  the  food, 
and  secondly,  through  salt  losses  due  to  excessive  intes- 
tinal secretion,  as  seen  in  this  condition.  These  abnormal 
processes  result  in  a  relative  acidosis,  an  acidosis  of  en- 
teric origin.  And  as  a  result  of  such,  enteral  loss  of 
salts  and  markedly  increased  NH-excretion  takes  place, 
which  is  evidenced  clinically  by  increase  of  ammonia  in 
the  urine. 

To  cover  these  losses,  salts  deposited  in  the  tis- 
sues are  in  part  withdrawn,  and  finally  the  cells  them- 
selves are  destroyed  through  being  deprived  of  their 
salt  content  (mineral  hunger).  It  should  be  remem- 
bered that  an  abnormal  fat  metabolism  is  frequently  the 
essential  factor  in  the  etiology  of  this  condition,  due  to  an 
overstepping  of  the  fat  tolerance.  And  further  that 
fermentative  changes  in  the  carbohydrates  produce  in- 
creased acidity  of  the  contents  of  the  intestinal  canal, 
and  so  enhance  the  action  of  fats.  While  there  is  usually 
an  excess  of  protein  loss  over  protein  assimilation,  the 
tolerance  for  proteins  is  usually  less  affected.  Because 
of  the  loss  of  nitrogenous  substances  due  to  a  relative 
excess  in  excretion  of  NH,  proteins  must  be  utilized  in 

the  diet  to  counteract  these  losses. 

14 


210  INFANT   FEEDING. 

Increased  peristalsis  in  diarrheal  conditions  results  in 
further  inanition,  due  to  the  passing  of  undigested  food 
through  the  intestinal  tract.  The  ''decomposition"  of 
the  organs  essential  to  life  finally  leads  to  an  alteration 
of  the  condition  of  the  cells  and  of  their  functions,  which 
results  in  the  death  of  the  organism. 

Symptoms.  The  cardinal  symptoms  of  decomposi- 
tion are  intolerance  to  food  and  great  loss  of  weight. 

1.  Lack  of  ability  to  assimilate  food  is  pathognomonic 
of   this   condition.     The   paradoxical   reaction   to    food, 


Fig,  11. — Infant  with  decomposition. 

mentioned  in  the  two  preceding  stages  of  nutritional  dis- 
turbances, becomes  here  a  striking  and  serious  phenom- 
enon. Starvation  or  the  institution  of  the  hunger  day  as 
a  therapeutic  measure  in  these  infants  not  infrequently 
results  in  an  inanition  which  is  fatal  to  the  infant. 
Again,  too  rapid  increases  in  the  diet  are  equally  serious, 
and  not  infrequently  precipitate  alarming  and  fatal  symp- 
toms. When  the  condition  has  progressed  to  this  degree, 
human  milk  alone  offers  hope  of  recovery. 

2.  Loss  in  weight  is  the  second  cardinal  symptom  of 
decomposition,  due,  as  the  name  of  this  condition  sug- 
gests, to  disintegration  of  the  body  substance.  This  may 
be  slight  in  the  beginning,  and  in  the  light  cases ;  in  the 


THE    STAGE   OF   DECOMPOSITION. 


211 


^  i 

Q  •<  ^  O 

O 

IS 

< 

1 

a 

rli 

liii 

o 

Z 

< 

Z 

c 
c 

p- 

d 

c 
a: 

.0 
.2       "a 

1       & 

Q  a 

>■ 
It 

a 

_ii^  -_;^ 

^             ^! 

'    I' 

~ 

iC< 

r— i          .; 

' 

-aJ ^^ 

^  \         ^i 

4   + 

^  1^ 

:::::r:::::?^ 

'^f- 

V     .^ 

"'^^vr""i^ 

«-'t£, 

J    /    f^ 

a:                    = 

\         1                  ^0 

/       'v            I 

\  r~^ 

_  J               _s       - 

..^      \         ? 

..___.;:5::::j 

'^(V 

__._-      \     \-; 

^ 

t   4q 

3^ 

t           ^^    f^ 

■'■ 

, 

ooc 

lOl. 

" 

3       yO^l    ua^.g-oj  Z7(S^ 

—ica. 

'         1  X 

T 

1 

1       : 

.^< ! 

_-..      .'?'    i-^ 

s 

'K     ^^ 

1 

: 

^11                          i 

— -.i--.:.___5^ 

^^    ShH   7l*/U2       go  )S       JlJ^d 

:>    /            (lP'\yd?i  diiro  Z 

fix 

gXii 
gxo: 

^""3   yiHf5f  ET"H0IIfB'35""C;D: 

^                                             1 

^     /      n 

^ 

^      — - J 

/       -t-^s 

s                                               / 

i        . 

-J 

Z 

|X^ 

-__.::::"" 

2                             ' 

h 

7 

o 
u 

IKI. 

|:<o 

IX 

■ 

^                                                           1 

-1-      ^                    z» 

1   /           <^ 

-^                   -^   J- 

(-      „ 

T 
1 

G 
t 

1 

^     __              1  / 

-— Z.._     5 

1  ^^             5; 

+ 

c 

+ 

to 
to_ 

OOC 

CI 

lot 

:::^±::::"i5 

1   °               NOuvDiaaw 

SNOldKAS                 a 

6 

o     o     o-     »     *    li 

ii       i 

i! 

anUQ    ^ 

-'      J,      '      '      1      1     J     1 
s      §    S    g    §    s    s   s 

3      §      i      ^      ^      ^     ,    § 
1       ,                          " 

r"       =                    3                     O                     o 

s         Sf          <o          't 

^333 

<0           CO          ic 

O               c5               CO                  ^     g 

s         s         s          5  g 

=0           1-            t-            't^    * 

psom 

aoo 

soiniOA                  s| 

4 

212  INFANT   FEEDING. 

later  stages  and  in  severer  cases,  however,  it  is  often 
sudden  and  rapid,  and  may  reach  daily  losses  from  1  to 
3  ounces  (30  to  100  Gm.),  resulting  eventually  in  a  pic- 
ture of  marasmus.  The  baby  becomes  thin,  emaciated, 
wrinkled,  with  prominent  ribs,  covered  with  tightly 
drawn  skin,  and  with  intercostal  spaces  deeply  marked 
(skeleton-like).  The  tissues  are  soft  and  flabby,  the 
muscles  either  relaxed  or  hypertonic,  the  abdomen  pro- 
tuberant, usually  distended,  the  color,  pale  first,  later 
changing  to  characteristic  grayish-white,  with  more  or 
less  cyanotic  lips,  fingers  and  toes.  The  mouth  appears 
large,  the  cheeks  sunken,  and  the  facial  expression 
anxious  and  serious.  These  characteristics  give  the  in- 
fant the  appearance  of  a  wrinkled  old  man.  As  has  been 
previously  stated,  in  the  earlier  stages,  these  babies  are 
irritable  and  apparently  in  constant  distress,  cry  a  great 
deal,  and  are  excessively  hungry.  In  the  later  stages, 
however,  they  are  often  apathetic,  and  apparently  too 
weak  to  perform  voluntary  movements.  When  they 
have  reached  this  stage,  they  are  subject  to  sinking  spells 
— that  is,  periods  in  which  their  vitality  is  very  low. 
These  may  become  very  alarming,  and  often  result 
fatally. 

3.  Vomiting  is  frequent. 

4.  The  hunger  is  often  very  great,  and  extremely  diffi- 
cult to  satisfy. 

5.  Subnormal  temperatures,  ranging  from  96°  to 
98°  F.,  with  an  irregular  daily  curve  is  the  rule.  The 
temperature  can  easily  be  raised  to  100°  or  more  by  the 
application  of  artificial  heat  (hot  water  bottles,  etc.), 
and  can  sink  quite  as  rapidly  and  alarmingly  when  the 
artificial  heat  is  removed. 


THE    STAGE   OF   DECOMPOSITION.  213 

6.  The  pulse  is  often  slow  and  small,  and  the  heart- 
beats weak,  and  often  only  one  heart  tone  is  heard  at 
the  apex. 

7.  Respiration  becomes  rapid,  and  the  expirations  pro- 
longed. The  breathing  becomes  irregular,  even  to  the 
Cheyne-Stokes  type. 

8.  The  sensorium  is  not  involved  in  these  infants,  and 
when  not  too  weak  they  take  cognizance  of  their  sur- 
roundings, are  alert,  and  sleep  but  little. 

9.  The  urine  usually  shows  an  increased  ammonia  out- 
put.    It  may  contain  albumin,  but  very  rarely  sugar. 

10.  The  stools  are  variable,  mostly  dyspeptic,  occa- 
sionally diarrheal.  In  the  earlier  stages  and  in  periods 
of  remissions  they  may  be  quite  firm  (soap  stools),  again 
soft  and  firm  stools  may  alternate.  The  hunger  stool — 
small,  dark,  and  containing  much  mucus — is  common, 
especially  in  advanced  cases,  with  an  inability  to  take 
proper  diet.  Dark-brown,  black,  and  tarry  stools  indi- 
cate usually  hemorrhages  from  ulcers  m  duodenum 
(Helmholtz).  We  therefore  learn  to  recognize  the  char- 
acter of  the  stools  as  being  only  of  secondary  importance 
in  the  diagnosis,  and  also  of  secondary  importance  for 
treatment.  We  must  not  be  misled  into  further  starva- 
tion because  of  temporary  changes  in  character,  even  for 
the  worse,  of  the  stool,  due  to  the  changes  in  the  diet 
instituted  for  therapeutic  purposes. 

11.  These  infants  are  peculiarly  susceptible  to  infec- 
tions, and  even  slight  infections  of  the  skin,  respiratory, 
gastro-intestinal,  and  genito-urinary  tracts  may  prove 
fatal. 

12.  Edema,  cyanosis,  and  a  more  or  less  generalized 
purpura  are  not  infrequently  forerunners  of  an  impend- 
ing death. 


214  .  INFANT    FEEDING. 

Diagnosis.  The  diagnosis  in  severe  cases  may  be 
made  from  the  cHnical  picture  of  the  condition,  but  it  is 
necessary  to  exclude  emaciation  due  to  tuberculosis, 
syphilis  and  cachexia  caused  by  other  disease,  and  also 
by  simple  inanition,  due  to  prolonged  underfeeding.  This 
is  to  be  based  on  the  history  and  examination  of  the  in- 
fant. In  lighter  cases  it  is  necessary  to  differentiate  espe- 
cially from  disturbed  metabolic  balance  and  from  simple 
dyspepsia,  since  the  treatment  which  improves  these  con- 
ditions may  do  considerable  harm  in  infants  suft'ering 
from  decomposition..  The  status  prsesens  is  not  sufficient 
for  making  the  diagnosis,  since,  as  previously  mentioned, 
remissions  with  stationary  weight  and  good  stools  often 
occur.  In  these  cases  the  history  is  of  utmost  impor- 
tance :  repeated  diarrhea,  loss  in  weight  and  febrile  in- 
fections should  lead  one  to  suspect  decomposition.  The 
positive  diagnosis  is  made  upon  the  reaction  of  the  in- 
fant to  food.  If  on  somewhat  increasing  the  diet  a 
marked  and  .severe  paradoxical  reaction  appears  (diar- 
rhea, loss  of  weight,  and  occasionally  fever),  decomposi- 
tion should  be  suspected. 

Prognosis.  We  must  remember  that  while  primarily 
the  picture  of  the  disease  is  a  nutritional  one,  the  death 
is  frequently  brought  about  by  infection. 

The  prognosis  depends  on  the  following  factors  :  ( 1 ) 
The  stage  of  decomposition.  When  the  loss  of  weight 
has  reached  one-third  of  the  body  weight.  (Quest's  fig- 
ure), then  the  reparation  under  any  treatment  seems  to 
be  impossible.  (2)  The  nature  of  the  dietetic  treatment, 
and  especially  the  possibility  of  feeding  with  human  milk. 
If  one  avoids  the  common  errors,  even  the  severe  cases 
may  be  saved,  except  when  the  treatment  is  started  too 
late.  (3)  The  extent  of  the  lowered  immunity.  The 
prognosis  should  always  be  guarded. 


THE    STAGE    OF    DECOMPOSITION.  215 

Improvement  is  common  even  in  severe  cases,  but  there 
is  a  great  tendency  to  sinking  spells  and  collapse.  Death 
in  these  cases  is  sometimes  remarkably  sudden.  It  usu- 
ally occurs  in  one  of  the  following  ways :  ( 1 )  By  sud- 
den syncope.  (2)  By  apparent  paralysis  of  the  respira- 
tory center.  Periods  of  apnea  usually  precede  the  latter. 
There  is  no  disturbance  of  consciousness.  The  face  looks 
gray,  and  the  eyes  are  staring.  The  breathing  becomes 
irregular  and  slow,  the  heart  weakens,  the  temperature 
sinks  far  below  normal,  cyanosis  increases,  and  breath- 
ing gradually  stops.  Sometimes  the  heart  stops  first. 
Such  death  may  extend  over  days. 

Treatment.  Prophylaxis  is  the  key-word  to  success- 
ful treatment.  A  recognition  and  proper  interpretation 
of  minor  nutritional  disturbances  will  avoid  the  graver 
conditions. 

For  a  proper  conception  of  the  therapeutic  needs  we 
must  recognize : 

1.  That  we  have  a  chronic  condition  which  is  subject 
to  acute  catastrophes. 

2.  That  the  younger  the  infant  and  the  greater  the  pre- 
ceding dietetic  errors,  the  graver  are  the  consequences 
of  decomposition. 

3.  That  starvation  is  dangerous. 

4.  That  food  is  assimilated  with  difficulty. 

5.  That  the  downward  weight-curve  is  likely  to  drop 
suddenly  with  improper  feeding  and  intercurrent  in- 
fection. 

Two  essentials  are  necessary  to  the  successful  treat- 
ment of  the  majority  of  cases  of  decomposition:  (1) 
avoidance  of  prolonged  starvation,  and  (2)  human  milk. 
It  is  the  misfortune  of  most  of  these  infants  to  have 
their  abnormal   stools,   or  more   commonly,   the   hunger 


216  INFANT    FEEDING. 

stools  previously  described,  interpreted  as  an  indication 
for  starvation,  regardless  of  the  fact  that  the  baby  is 
already  starving.  It  has  been  our  experience  not  only 
to  have  seen  one  day  of  star\^ation,  but  repeated  periods 
of  starvation  the  rule,  because  of  misinterpretation  of 
the  significance  of  the  ''starvation  stools."  A  single  day 
of  starvation  is  often  svifficient  to  kill  an  advanced  case, 
and  even  prolonged  underfeeding,  below  60  calories  per 
kilogram  (the  amount  required  to  sustain  the  body 
equiHbrium),  has  a  very  harmful  effect.  Starvation  from 
without  is  thus  added  to  inanition  from  within. 

1.  Feeding  with  Human  Milk.  It  must  be  given  in 
moderate  quantity,  best  guarded  by  drawing  off  and 
feeding,  as  these  infants  drink  too  rapidly  (always  hun- 
gry), and  do  not  stand  large  amounts.  About  200  to 
300  mils  daily  is  enough  to  sustain  the  infants  tempor- 
arily (60  calories  per  kilogram  is  sustaining — Rosen- 
stern).  Feed  often;  ten  feedings  may  be  given,  one 
every  two  hours  (10  to  20  mils),  weak  tea  or  saccharin 
water  ad  libitum  between  feedings.  The  daily  quantity 
should  be  increased  as  rapidly  as  possible  (at  least  every 
other  day),  until  not  later  than  after  7  to  10  days  about 
100  calories  (130  to  150  mils)  per  kilogram  are  admin- 
istered. The  number  of  feedings  should  gradually  be 
decreased  as  the  condition  improves,  and  direct  nursing 
on  the  breast  may  be  tried  later,  but  the  danger  of  over- 
feeding must  not  be  overlooked. 

Weight  may  still  not  improve  for  some  time.  This 
Keller  calls  ''reparation  stage/'  Even  on  feeding  with 
human  milk  there  is  a  shorter  or  a  longer  period  of 
stationar}^  weight  (depending  on  the  severity  of  the 
case),  which,  however,  is  accompanied  by  improvement 
of  the  symptoms.  Those  who  have  not  had  experience  in 


THE   STAGE   OF    DECOMPOSITION.  217 

these  cases  may  be  inclined  to  blame  the  wet-nurse,  and 
advise  a  change.  This,  however,  is  constant  in  the  stage  of 
reparation,  in  which  the  body  is  being  reconstructed,  with- 
out being  able  to  put  on  weight,  this  being  partially,  at 
least,  due  to  still  deficient  absorption,  and  partially  also 
to  the  fact  that  the  human  milk,  containing  comparatively 
small  quantities  of  proteins  and  salts,  furnishes  only  a 
limited  quantity  of  material  for  rebuilding  of  the  body. 
Only  after  this  period  the  gain  in  weight  begins.  This 
may  be  shortened  by  feeding  daily  100  mils  of  boiled 
buttermilk  or  skim  milk,  which  is  rich  in  salts  and  pro- 
teins, both  of  these  substances  hastening  weight  increase. 
This  is  not  to  be  done  until  after  the  third  or  fourth 
week  of  treatment,  and  with  a  close  observation  of  the 
results.  It  may  be  fed  by  mixing  with  and  distributing 
through  the  breast  feedings. 

Carbohydrates  should  be  added  with  even  greater  care, 
adding  4  Gm.  at  a  time  to  the  day's  feeding.  In  older 
infants  a  small  amount  of  farina  soup  or  zwieback  in  tea 
may  be  tried  later. 

The  complete  recovery  is  not  to  be  expected  sooner 
than  in  two  to  three  months.  And  only  then  should  the 
return  to  artificial  feeding  be  thought  of.  The  weaning 
should  be  preceded  by  experimental  administration  of 
small  quantity  of  whole  cow's  milk,  as  there  is  a  possibil- 
ity of  idiosyncrasy  to  cow's  milk. 

2.  Artificial  Feeding,  If  there  is  no  possibility  of 
feeding  an  infant  suffering  from  decomposition  other- 
wise than  with  artificial  food  mixtures,  then  the  same 
rules  are  to  be  followed  as  have  been  given  for  dyspepsia. 
In  this  condition  also  the  first  thought  should  be  of  boiled 
buttermilk  and  skim  milk  mixtures,  with  a  low  percent- 
age of  fat,  diluted  with  gruels,  and  containing  a  moder- 


218  IXFAXT    FEEDIXG. 

ate  quantity  of  slowly  fermentable  carbohydrate,  such  as 
maltose-dextrin  compounds  (see  Appendix),  fed  in  small 
quantities  at  frequent  intervals. 

In  mild  cases  feedings  of  30  mils  ( 1  ounce )  8  times 
daily,  and  in  severe  cases  10  or  12  feedings  of  15  mils 
(0.5  ounce),  n:ay  be  given  in  the  twenty-four  hours. 
The  buttermilk  can  be  replaced  by  skim  milk,  if  the 
former  is  not  well  taken.  Flour  ball  or  dextrinized  barley 
flour  can  be  used  in  place  of  ordinary  wheat  flour  to  ad- 
vantage, and  maltose-dextrin  compounds  can  be  used  in 
place  of  cane-sugar. 

Brady's  mixture  Xo.  1  can  frequently  be  used  to  bet- 
ter advantage  in  the  same  quantities  (see  Appendix, 
p.  284). 

The  individual  meals  should  be  increased  so  as  to 
meet  the  infant's  caloric  needs  as  rapidly  as  the  condi- 
tion allows. 

AMiile  in  simpler  forms  of  nutritional  disturbances  the 
intestine  recovers  within  a  short  time  to  such  an  extent 
that  the  feeding  may  be  more  liberal,  in  severe  decom- 
position the  increase  of  food  is  often  followed  by  aggra- 
vation of  the  condition.  Administration  of  farinaceous 
foods  alone  is  also  risky,  because  of  the  danger  of  fur- 
ther inanition.  From  this  it  becomes  apparent  how 
limited  is  the  outlook  for  good  results  in  the  extreme 
cases  of  this  condition  with  artificial  feeding,  especially 
when  occurring  in  very  young  infants. 

Recent  experience,  however,  has  taught  us  that  the 
boundaries  of  curability  can  be  considerablv  broadened 
by  the  use  of  the  albumin  milk  of  Finkelstein.  The  ob- 
ject of  the  albumin  milk  is  to  limit  as  much  as  possible 
the  injurious  acid  fermentation,  which  is  accomplished 
by  diminution  of  the  percentage  of  milk-sugar  below  that 


THE    STAGE    OF    DECOMPOSITION.  219 

contained  in  cow's  milk,  by  the  removal  of  some  of  the 
whey,  whereby  the  tolerance  of  the  intestine  for  the 
sugar  is  improved.  By  the  administration  of  large 
amounts  of  finely  divided  casein  as  contained  in  the 
albumin  milk,  alkaline  reaction  is  produced  which  is 
antagonistic  to  acid  fermentation.  It  also  contains  over 
2  per  cent,  of  fat,  which  can  be  digested  by  these  infants 
in  all  probability  because  of  the  small  quantity  of  sugar 
and  salts  contained  in  the  albumin  milk. 

The  advantage  of  the  treatment  with  albumin  milk, 
consists  in  the  fact  that  it  is  possible  to  reach  sufficient 
feeding  quantities  much  more  rapidly  than  with  most 
other  artificial  foods,  without  the  danger  of  exciting 
anew  the  fermentative  processes.  Thereby  the  danger 
of  inanition  is  avoided  and  reparation  is  accelerated. 

In  the  mild  cases  of  decomposition  we  start  after  an 
interval  of  six  hours  on  tea',  with  administration  of  300 
mils  of  albumin  milk,  with  an  addition  of  3  per  cent,  of 
maltose-dextrin  preparations  (milk-sugar  is  not  advis- 
able, and  even  the  cane-sugar  is  not  so  reliable),  divided 
into  5  or  6  meals,  and  with  further  addition  of  tea.  In 
the  days  that  follow,  without  paying  any  attention  to  the 
stools,  the  quantity  of  albumin  milk  is  increased,  every 
other  day  by  100  mils.  In  the  presence  of  firm  stools  it 
is  increased  even  more  rapidly,  until  a  daily  quantity  of 
180  to  200  mils  per  kilogram  (3  ounces  per  pound  body 
weight)  is  reached.  A  total  daily  quantity  of  1000  mils 
of  albumin  milk  is  rarely  to  be  exceeded.  In  typical 
cases  dry  fat-soap  stools  appear  after  one  to  two  days, 
this  is  followed  by  cessation  of  weight  loss,  and  repara- 
tion proceeds  undisturbed. 

After  the  quantity  of  food  necessary  to  sustain  the 
infant  is  reached,  sugar  may  be  gradually  increased  from 


220  INFANT   FEEDING. 

3  to  5  per  cent.  Dextrinized  starches  in  the  form  of 
flour  ball  (imperial  granum),  or  dextrinized  barley  flour 
in  quantities  of  1  or  2  per  cent,  of  the  mixture,  can  often 
be  added  to  advantage  to  albumin  milk  before  adding 
sugars. 

In  severer  grade  of  decomposition  the  intestine  is  also 
to  be  evacuated  by  a  short  period  of  hunger.  In  spite 
of  the  danger  of  inanition,  six,  or  at  most  twelve,  hours 
on  tea  cannot  be  avoided.  This  is  to  be  followed  by  the 
administration  of  albumin  inilk,  best  with  frequent  meals 
(8  to  10),  on  the  first  day  200  to  300  mils,  and  then,  as 
previously  advised,  rapid  increase  with  gradual  diminu- 
tion of  the  number  of  meals  and  increase  in  the  addition 
of  carbohydrates.  If  the  initial  loss  in  weight  does  not 
stop  within  three  to  four  days,  and  if  the  child 
shows  languor  and  tendenc}^  to  subnormal"  temperature, 
then  the  addition  of  carbohydrates  must  be  increased, 
even  in  the  presence  of  frequent  stools,  until  the  loss 
stops. 

If  we  proceed  in  this  way,  then  the  number  of  unsuc- 
cessful cases  becomes  considerably  smaller.  Experience 
has  shown  that  in  albumin  milk  therapy  often  an  error 
is  made  which  frequently  leads  to  failure  by  underfeed- 
ing. It  should  be  remembered  that  albumin  milk  has  a 
caloric  value  of  only  about  12  to  the  ounce,  and  therefore 
this  feeding  must  be  carefully  guarded  to  avoid  (1)  too 
slow  initial  increase,  thereby  prolonging  inanition,  (2) 
omission  of  carbohydrates  or  insufficient  increase  of  the 
same,  (3)  repeated  restriction  of  the  quantity  of  the 
food,  or  withholding  carbohydrates  when  the  temperature 
rises  or  diarrhea  reappears.  All  these  are  to  be  avoided. 
Only  when  sudden  loss  in  weight  and  violent  diarrhea  set 
in,   should  the  total  quantity  of  the   food   be   reduced. 


THE    STAGE   OF   DECOMPOSITION.  2^1 

After  disappearance  of  these  acute  symptoms  the  increase 
must  be  made  as  soon  as  possible. 

In  the  beginning  of  the  treatment  with  albumin  milk, 
exacerbations  similar  to  those  that  occur  on  feeding  with 
human  milk  may  occur,  and  these  should  not  lead  to 
starvation.  Later,  the  gain  is  rapid,  provided  that  suffi- 
cient quantities  of  carbohydrates  have  been  added. 

The  duration  of  feeding  with  albumin  milk  is  about 
six  to  eight  weeks  for  the  younger  infants,  and  four  to 
six  weeks  for  the  older  infants.  After  this  time  the  dis- 
ease is  cured  usually  to  such  an  extent  that  ordinary  milk 
mixtures,  corresponding  to  the  child's  age  and  weight 
may  well  be  taken.  The  change  is  best  made  by  replacing 
all  the  feedings  of  albumin  milk  mixtures  at  one  time. 
This  is  frequently  followed  by  bad  stools  for  a  day  or 
two,  which  should  not  lead  one  to  discontinue  the  new 
diet.  The  quantity,  however,  should  not  be  further  in- 
creased until  they  show  some  improvement. 

If  a  relapse  occurs,  then  it  is  necessary  to  return  to 
feeding  with  albumin  milk  for  some  additional  time. 

One  may  speak  of  a  complete  cure  of  this  nutritional 
disturbance  in  an  infant  only  when,  after  discontinuation 
of  albumin  milk  and  return  to  the  usual  milk  mixtures, 
with  careful  dosage,  the  development  proceeds  without 
any  disturbance. 

Medicinal  Treatment.  This  is  practically  limited  to 
stimulation  in  the  presence  of  collapse  and  sinking  spells, 
and  the  favorite  stimulant  is  camphor  given  intramus- 
cularly in  the  form  of  a  sterilized  camphorated  oil  (5  to 
10  drops  every  two  to  four  hours).  Alcohol  is  appar- 
ently of  benefit  in  severe  cases.  Five  to  15  drops  of 
whisky  or  brandy  every  two  to  four  hours.  In  the 
severer  types  transfusion  is  also  indicated. 


222  INFANT   FEEDING. 

Artificial  heat  must  be  applied  in  all  cases  with  a  de- 
cided tendency  to  low  temperatures.  This  must  not  be 
overdone,  since  the  child's  temperature  can  easily  be 
raised  above  the  nonnal,  and  act  as  unfavorably  as  sub- 
normal temperature. 


CHAPTER    VI. 
THE  STAGE   OF   ALIMENTARY   INTOXICATION. 

Synonyms.  Gastro-enteric  intoxication  (Holt),  catar- 
rhal enteritis,  cholera  infantum,  summer  diarrhea. 

Definition.  This  is  not  a  disease,  but  a  general  toxic 
state,  characterized  by  a  symptom-complex  in  which  diar- 
rhea and  irritability  of  the  central  nervous  system  are 
the  most  characteristic  signs  of  the  toxemia. 

The  graver  the  preceding  nutritional  disturbances,  i.e., 
the  closer  the  infant  approaches  the  stage  of  decomposi- 
tion, the  more  readily  does  the  stage  of  intoxication  de- 
velop. Collapse  and  nervous  symptoms  outweigh  the  in- 
testinal symptoms. 

Etiology.  All  factors  which  cause  nutritional  disturb- 
ances can  be  active  factors  in  the  causation  of  intoxica- 
tion: Although  frequently  a  primary  food  disturbance, 
it  is  more  commonly  seen  as  a  food  disturbance  secondary 
to  some  other  factor.  Among  the  most  important  of 
these  are : 

1.  Food. 

(a.)  Combination  of  food  elements  which  individ- 
ually would  be  insufficient  to  cause  a  dis- 
turbance. 

(&)  Infected  food — that  is,  spoiled  milk,  not  com- 
monly due  to  the  bacteria  themselves,  but  to 
their  activity  on  the  fats  and  sugars,  and  the 
formation  of  toxic  bodies  (Czerny  and 
Keller). 

2.  Infections.  They  are  not  due  to  a  single  factor. 
We  must  believe  that  the  infections  injure  the  intestinal 

(223) 


224  INFANT   FEEDING. 

wall  and  other  digestive  organs.  From  this  point  the 
pathogenesis  is  the  same  as  in  alimentary  intoxication. 
The  toxic  influences  of  different  infections  are  as  differ- 
ent as  are  the  infections. 

(a)  Gastro-intestinal  infections   (enteral  infection). 

(See  chapter  IX.) 

(b)  Systemic  infection,   as   otitis,   cystitis,   pharyn- 

gitis,  etc.    (parenteral   infection).     Intoxica- 
tion is  frequently  seen  following  in  the  wake 
of  or  occurring  during  infections  due  to  the 
disturbances  in  the  digestive  functions.     (See 
chapter  IX.) 
3.  Heat.     This   can   cause   a   chain  of   symptoms  re- 
sembling intoxication.     As  to  the  exact  cause  there  has 
been  much  speculation,  and  it  is  not  yet  satisfactorily 
settled.    We  cannot  overlook  the  fact  that  in  many  cases 
a   chain   of   symptoms    resembling   intoxication   is   seen, 
seemingly  due  to  bacterial  action  on  the  milk,  and  the 
subsequent  production  of  toxic  bodies. 

These  facts  are  established:  that  infants  are  greatly 
depressed  and  debilitated  by  heat,  and  therefore  can 
stand  less  food  in  the  hot  months.  It  is  also  true  that 
less  food  is  required  during  the  summer  months  to  nour- 
ish an  infant,  and  this  should  be  taken  advantage  of  as 
a  prophylactic  therapeutic  measure.  Unfortunately,  this 
is  not  heeded  in  many  cases,  because  the  child  is  more 
thirsty,  and,  its  food  being  liquid,  quenches  its  thirst, 
and  is  therefore  given  in  excessive  amounts ;  and  sec- 
ondly, because  the  cry  and  discomfort  due  to  the  same 
overfeeding  and  heat  are  interpreted  as  hunger.  It 
should  therefore  be  the  duty  of  the  physician  to  warn 
against  excessive  feeding  during  the  hot  summer  months ; 
that  these  latter  are  factors  is  evidenced  by  the  fact  of 


STAGE  OF  ALIMENTARY  INTOXICATION.       225 

their  prevalence  among  the  poor  and  ignorant.  Summing 
up  the  situation,  we  can  state  with  positiveness  that  all 
depends  upon  the  individual  resistance;  a  more  severe 
irritant  is  necessary  in  those  suffering  with  disturbed 
metabolic  balance  and  dyspepsia  than  in  the  atrophic  in- 
fants to  develop  the  stage  of  intoxication. 

To  recapitulate :  to  develop  intoxication  there  must  be 
a  pre-existing  nutritional  disturbance  or  an  injured  in- 
testinal epithelium.  Enteric  and  systemic  infections,  as 
well  as  heat,  predispose  to  intoxication  through  their 
action  on  the  cells  of  the  digestive  apparatus  of  the  in- 
testinal and  secretory  glands,  and  general  systemic  effect. 
The  resemblance  of  these  cases  to  an  infection  naturally 
leads  to  the  belief  that  they  are  due  either  to  infection  of 
the  intestinal  mucous  membrane  or  to  the  absorption  of 
bacterial  toxins  from  spoiled  milk.  While  infections  or 
toxins  may  cause  a  similar  picture,  in  a  large  group  of 
cases  they  will  not  explain  the  clinical  findings — first,  be- 
cause the  symptoms  disappear  upon  withdrawal  of  the 
food;  secondly,  they  may  appear  during  the  feeding  of 
aseptic  milk  as  well  as  septic,  and  that  no  pathological 
findings  are  found  that  could  explain  the  symptoms. 
Again,  increases  of  food  above  the  child's  tolerance  will 
cause  relapses,  and  food  withdrawal  will  again  cause  a 
rapid  improvement. 

Pathogenesis.  Several  factors,  either  individually 
or  together,  can  cause  the  group  of  symptoms  charac- 
teristic of   alimentary  intoxication. 

1.  The  symptoms  may  be  due  to  the  toxicity  follow- 
ing absorption  of  imperfectly  elaborated  products  of  the 
intermediary  metabolism.  These  are  the  type  of  cases 
described  by  Finkelstein  in  his  "Food  Injuries,"  and  rep- 
resent the  fourth  stage  in  the  progressive  intolerance  for 

15 


226  INFANT   FEEDING. 

food.  The  less  the  infant's  tolerance,  i.e.^  the  closer  it 
approaches  the  stage  of  decomposition,  the  smaller  the 
amount  of  food  necessary  to  produce  an  intoxication 
(Finkelstein).  The  precipitating  factors  are  the  same 
as  in  dyspepsia — that  is,  the  sugar  and  whey  (lactose  and 
salts)  content  in  the  food — but  here  we  have  a  more 
severe  picture.  The  alimentary  glycosuria,  which  fre- 
quently occurs,  is  evidence  of  a  disturbance  in  the  carbo- 
hydrate metabolism.  Sugars  of  the  type  ingested  may 
be  seen  in  the  urine  long  before  the  end  of  the  proper 
assimilation  pen'od.  This  ceases  when  the  sugar  is  with- 
drawn from  the. diet.  Fat  can  also  produce  toxic  symp- 
toms, but  this  can  in  all  probability  occur  only  after  the 
sugar  has  acted  harmfully,  or  when  the  infant  is  in  or 
approaching  the  stage  of  decomposition,  or  after  a  severe 
infection  has  seriously  affected  the  infant's  metabolism. 
This  in  turn,  together  with  the  hunger  and  loss  of  alka- 
lies due  to  vomiting  and  diarrheal  stools,  may  bring 
about  an  injury  to  fat  metabolism  which  may  be  evi- 
denced as  an  acidosis.  Meyer  found  fat  absorption  re- 
duced from  97  to  60  per  cent.  This  improves  early  in 
convalescence.  Splitting  of  fats  is  bad,  and  we  get  an 
acidosis  with  the  presence  of  acetone  and  aceto-acetic 
acid,  butyric  acid,  etc.,  in  the  urine  (Rosenstern).  When 
this  stage  is  reached,  there  is  also  another  probability^ — 
that  of  interference  with  protein  metabolism ;  but  whether 
or  not  this  has  any  effect  upon  the  picture  rendered  by 
intoxication  is  open  to  question.  It  is  questionable 
whether  the  salt  loss  is  the  primary  cause  of  the  water 
loss,  or  whether  the  loss  of  water  by  the  system  has  its 
own  pathogenesis.  Indeed,  it  would  require  a  great  salt 
loss  to  account  for  the  great  loss  of  water,  and  it  is  quite 
possible  that  a  toxic  influence  results  in  a  disturbance  of 


STAGE  OF  ALIMENTARY  INTOXICATION.       227 

the  water-binding  property.  The  great  water  loss  also 
causes  accumulation  of  toxic  products  and  products  of 
metabolism  in  concentrated  solutions. 

In  such  a  general  failure  of  metabolism,  we  have  to  as- 
sume a.  severe  damage  of  the  corresponding  organs  and 
cells.  We  have,  therefore,  when  the  picture  is  complete, 
an  insufficiency  of  all  the  functions  of  the  intermediary 
metabolism    (metabolic    bankruptcy — Finkelstein). 

2.  The  symptoms  may  be  due  to  a  relative  acidosis 
dependent  upon  an  excessive  loss  of  bases,  more  espe- 
cially sodium,  by  way  of  the  alimentary  tract,  through 
vomiting  and  the  diarrheal  stools.  This  is  evidenced 
clinically  by  the  increased  ammonia  content  of  the  urine. 
From  40  to  50  per  cent,  of  nitrogenous  compounds  of  the 
urine  do  not  appear  as  urea,  but  as  ammonia,  the  am- 
monia being  used  to  unite  with  the  acids  which  are  in 
relative  excess  in  the  blood.  Rowland  and  Merriet 
found  in  their  investigations  of  toxic  diarrheas  that  not 
alone  was  the  acidity  of  the  blood  increased,  but  that 
there  was  a  positive  evidence  of  acidosis,  as  shown  by  the 
diminution  of  carbon  dioxide  tension  of  the  alveolar  air. 
They  also  found  an  increased  tolerance  for  alkalies  in 
these  infants,  in  which  they  resemble  other  forms  of 
acidosis. 

3.  The  type  secondary  to  the  enteral  and  parenteral 
infections.  In  this  group,  two  further  factors  are  of  im- 
portance— first,  that  due  to  bacterial  invasion  in  the  infec- 
tions ;  and  second,  the  danger  of  absorption  of  the  toxic 
products  of  bacterial  fermentation  of  food  in  the  intes- 
tinal tract. 

Even  in  the  infective  types,  the  several  factors,  ab- 
sorption of  toxic  products  of  the  intermediary  metab- 
olism, the  relative  acidosis  due  to  alkali  losses  through 


228  INFANT   FEEDING. 

the  stools,  and,  lastly,  the  absorption  of  toxic  products 
from  the  intestinal  canal,  may  all  be  constituting  causes. 

4.  The  large  group  of  cases  seen  during  the  hot  sum- 
mer months  are  probably  due  to  a  combination  of  factors, 
— systemic  depression,  spoiled  milk  and  bacterial  invasion. 

We  have,  therefore,  a  clinical  picture  dominated  by 
nervous  and  intestinal  symptoms  which  may  be  caused 
by  a  variety  of  factors.  The  manifestations  may  be  the 
end  result  in  the  cause  of  chronic  nutritional  disturb- 
ances, with  a  steady  tendency  toward  metabolic  bank- 
ruptcy, or,  as  in  the  case  of  the  third  and  fourth  groups, 
the  effect  may  acutely  follow  the  absorption  of  products 
of  bacterial  fermentation  from  the  intestinal  tract  in  in- 
fants often  previously  strong  and  healthy.  In  all  of 
them  a  secondary  relative  acidosis  due  to  salt  losses 
through  vomiting  and  diarrhea  is  a  serious  complication. 
Again,  it  may  be  quite  impossible  to  decide  in  many  cases 
whether  the  products  of  intermediary  metabolism,  the 
secondary  relative  acidosis,  or  the  toxic  products  of  bac- 
teriological fermentation  are  the  most  important  factor  in 
the  causation  of  the  clinical  manifestations  on  the  part 
of  the  nervous  system. 

Symptoms.  1.  Fever.  A  rise  in  temperature  is  the 
first  symptom  of  an  alimentary  intoxication.  It  may  be 
slight,  or  it  may  go  up  to  104°  or  even  106°  F.  The 
height  of  the  temperature  is  not  always  a  direct  indica- 
tion of  the  severity;  in  fact  the  several  types  associated 
with  decomposition  may  have  a  low  temperature.  If  the 
case  be  one  of  true  intoxication,  prompt  withdrawal  of 
the  food  is  usually  as  quickly  followed  by  a  lower  tem- 
perature. However,  if  the  offending  food  is  continued, 
we  soon  have  other  symptoms  suddenly  and  to  an  alarm- 
ing degree. 


STAGE  OF  ALIMENTARY  INTOXICATION.       229 


230  INFANT   FEEDING. 

2.  Rapid  loss  in  zveight,  even  1  to  2  pounds  in  a  few 
days.  This  is  mainly  due  to  loss  of  water.  The  skin  be- 
comes dry  and  inelastic. 

3.  Vomiting  is  frequent,  and  may  contain  blood. 

4.  The  stools  are  liquid,  usualty  numerous,  and  con- 
tain mucus,  and  occasionally  blood.  In  the  severest  cases 
— cholera  infantum — the  stools  assume  a  rice-water  ap- 
pearance, move  almost  continuously,  and  are  often  asso- 
ciated with  tenesmus,  and  not  infrequently  prolapse  of 
the  rectum.  Exceptionally,  an  obstipation  is  seen  in 
place  of  the  diarrhea,  and  when  this  is  associated  with 
vomiting  and  abdominal  distension  one  cannot  help  but 
think  of  intestinal  obstruction. 

5.  Collapse.  The  skin  is  gray  in  hue,  and  becomes 
wrinkled.  The  eyes  are  sunken,  with  distant  stare,  and 
the  nose  assumes  a  pinched  appearance. 

6.  Nervous  symptoms  and  psychic  disturbances  are 
usually  pronounced,  and  often  lead  to  a  confusion  with 
meningitis.  The  infant  is  restless ;  the  sensorium  is  dis- 
turbed, with  an  occasional  cry  as  if  in  pain;  the  hydro- 
cephaloid  state  may  be  present,  with  strabism,  convul- 
sions, etc.  Before  these  more  severe  symptoms  develop, 
the  child  appears  apathetic,  drowsy,  and  dopy.  The  face 
assumes  a  fixed  expression,  and  there  is  a  tendency  on 
the  part  of  the  infant  to  lie  constantly  in  one  position, 
and  when  the  child  moves  its  extremities  it  does  so 
slowly,  as  if  too  tired  or  weak  to  change  its  position. 
The  arms  are  not  infrequently  flexed  in  an  attitude  re- 
sembling that  of  a  prize  fighter.  If  the  condition  in- 
creases in  severity,  stupor  and  coma,  associated  with 
twitchings,  convulsions,  strabismus,  and  other  meningeal 
symptoms,  ensue. 


STAGE  OF  ALIMENTARY  INTOXICATION.       231 

7.  Typical  respirations  (deep,  rapid,  without  pause), 
described  as  toxic  respirations.  The  respiratory  mani- 
festations may  vary  from  a  sHght  increase  in  number  and 
depth  to  a  marked  dyspnea. 

8.  Glycosuria  is  a  frequent  finding  in  the  type  due  to 
''food  injury,"  and  the  sugar  is  of  the  same  variety  as 
that  in  food;  thus,  milk-sugar  leads  to  lactosuria  and 
galactosuria.  This  glycosuria,  which  is  of  alimentary 
origin,  disappears  with  the  withdrawal  of  the  food.    The 


Fig.  14. — Infant  with  intoxication. 

phenylhydrazin  test  is  the  most  reliable  to  make,  as  the 
copper  sulphate  tests  require  long  boiling  with  lactose, 
etc.,  and  the  reaction  may  be  overlooked. 

9.  The  urine  contains  albumin  and  casts.  The  amount 
of  urine  is  small,  even  to  anuria. 

10.  Leukocytosis  is  present  up  to  30,000. 

11.  The  heart  action  is  weak,  and  the  pulse  small  and 
irregular. 

12.  Sclerema  is  constantly  seen  in  the  severer  types — 
a  very  bad  sign — due  to  a  coagulation  of  tissue  fluids  of 
an  unknown  nature  (Czerny  and  Keller). 

13.  Enlargement  of  the  liver  accompanies  the  severe 
types. 


232  INFANT   FEEDING. 

Pathology.  In  the  small  intestine  there  is  usually 
no  marked  change.  Hyperemia  of  the  mucous  mem- 
brane and  enlarged  follicles,  especially  Peyer's  patches, 
are  usually  present.  The  liver  shows  a  hyperemia, 
cloudy  swelling,  and  fatty  degeneration  (probably  caus- 
ing hepatic  insufficiency). 

Diagnosis.  The  diagnosis  is  based  on  the  above 
symptoms,  and  improvement  on  withdrawal  of  food. 
The  most  characteristic  and  striking  symptoms  are  those 
of  the  nervous  system  resulting  in  stupor,  pauseless 
respirations,  and  a  toxic  appearance.  These  are  asso- 
ciated with  diarrhea,  vomiting  and  a  rapid  loss  in  weight. 
The  history  of  preceding  nutritional  disturbances  and  in- 
fections are  of  great  importance  in  diagnosis. 

Prognosis.  This  depends  much  on  reaction  to 
hunger  diet,  as  very  severe  symptoms  disappear  often  in 
twenty-four  hours  of  starvation  in  the  ''food  injuries." 
If  the  same  do  not  disappear  in  this  time  in  this  class 
of  cases,  in  the  absenc-e  of  infection,  the  prognosis  is  bad. 
Infections  add  to  severity. 

Treatment.  1.  Removal  of  all  food  for  twelve  to 
twenty-four  hours,  with  sufficient  water  administration. 

2.  In  severe  types,  subcutaneous  salt  infusions  twice 
daily,  100  to  200  mils.  Ringer's  solution  may  be  used  to 
advantage  for  this  purpose. 

Gm.  or  rail 

NaCl    7.5 

KCl  0.1 

CaCl   0.2 

Water  1000.0 

The  water  used  in  making  this  solution  should  be  re- 
distilled shortly  before  using. 

If  the  infant  presents  evidence  of  acidosis,  sodium  bi- 
carbonate and   dextrose  may  be  added  to  the  Ringer's 


STAGE  OF  ALIMENTARY  INTOXICATION.       233 

solution,  and  administered  intravenously  in  young  infants 
through  the  longitudinal  sinus,  and  in  older  infants  into 
the  anterior  jugular  or  median  basilic  vein. 

About  4  Gm.  (60  gr.)  of  sodium  bicarbonate  and 
6  Gm.  (90  gr.)  of  dextrose  may  be  added  to  120 
mils  (4  ounces)  of  saline  solution,  and  repeated  in  four 
to  six  hours  if  indicated. 

It  should  be  remembered  that  intravenous  administra- 
tion of  large  amounts  of  sodium  bicarbonate  may  result 
in  collapse. 

Pure  dextrose  is  essential  (Kahlbaum's  is  a  good 
product).  If  dextrose  appears  in  the  urine,  the  adminis- 
tration should  be  stopped. 

3.  Salines  per  rectum,  best  administered  by  the  drop 
method.  Thirty  drops  per  minute  for  four  hours  is  450 
mils.  One-half  strength  of  Ringer's  solution  may  be 
used.  Sodium  bicarbonate,  5.0  Gm,  (75  gr.)  may  be 
added  to  every  500  mils  of  the  solution  (1  per  cent.). 

4.  One  lavage,  if  food  has  been  given  shortly  before, 
or  if  vomiting  is  severe. 

5.  Avoid  all  laxatives,  as  the  bowels  empty  them- 
selves, and  any  further  purgation  increases  the  loss  of 
salts  and  water,  and  increases  the  tendency  to  develop- 
ment of  an  acidosis. 

6.  Analeptics.  Give  a  mustard  bath  in  case  of  col- 
lapse.    Reddening  of  the  skin  is  a  good  sign. 

7.  Antipyretics.  Use  tepid  packs,  and  leave  the  in- 
fant undressed.  Ice-cap  to  head  is  useful,  but  should  not 
be  applied  directly  to  the  head,  because  of  the  thinness  of 
the  skull  in  young  infants. 

8.  Stimulants.  In  collapse,  warm  packs  or  baths  are 
indicated.  Caffein  sodium  benzoate,  0.006  Gm.  to  0.030 
Gm.  (0.1  to  0.5  gr.)   four  or  five  times  daily;  camphor- 


234  INFANT  FEEDING. 

ated  oil  in  1-mil  doses  every  two  hours  hypodermically 
if  indicated;  epinephrin  solution,  0.5  mil  (1  to  1000),  sub- 
cutaneously  or  intravenously. 

9.  Sedatives  for  convulsions.  Sodium  bromide  0.2 
Gm.  to  0.3  Gm.  (3  to  5  gr.)  repeated  in  three  to  four 
hours;  veronal,  0.05  Gm.  Chloral  hydrate  is  best 
avoided. 

10.  Opium  may  be  indicated  when  the  diarrhea  re- 
mains uncontrolled  by  other  methods.  Paregoric  in 
suitable  doses  per  mouth,  or  the  tincture  per  rectum  may 
be  used  with  care. 

11.  An  electric  fan  is  a  most  valuable  addition  to  our 
therapeutic  measures  in  summer. 

12.  Lumbar  puncture  may  be  indicated  in  the  presence 
of  increased  intracranial  pressure,  and  for  diagnostic 
purposes.  . 

13.  Diet.  Hunger  diet  should  be  employed  rarely 
longer  than  twenty-four  hours.  Occasional  administra- 
tion of  dilute  saHne  solutions  (NaCl  5,  XaHC03  5,  water 
1000)  per  mouth,  or  thin  gruels  may  soon  be  used  with 
care  to  supplement  an  occasional  feeding.  When  infant 
is  stuporous,  water  should  be  administered  by  gavage  at 
regular  intervals  of  about  three  to  four  hours. 

In  cases  of  food  intoxication,  twenty-four  hours  on  a 
hunger  diet  causes  striking  changes.  The  child  looks 
bright,  smiles,  and  to  all  appearances  looks  convalescing, 
notwithstanding  a  usual  loss  of  weight.  The  stools  also 
become  less  frequent,  and  although  small  and  containing 
mucus  (hunger  stools),  they  cause  less  irritation  of  the 
buttocks  and  little  loss  of  water.  The  improvement  is  no 
less  "striking  than  that  seen  in  the  crisis  of  pneumonia. 

Human  Milk.  Human  milk  is  by  all  means  the  best 
food.    Feed  often,  and  in  small  amounts,  ten  times  daily, 


STAGE  OF  ALIMENTARY  INTOXICATION.       235 

5  mils  from  bottle  or  spoon.  The  infant  may  also  be 
placed  directly  at  breast  for  one-  or  two-  minute  periods 
in  less  severe  cases.  Increase  when  the  temperature,  etc., 
do  not  react  to  food,  and  then  not  more  than  50  to  100 
mils  daily  increase  at  first.  After  several  days,  if  the  in- 
fant shows  no  evidence  of  relapse,  it  is  again  placed  un- 
restrictedly on  the  breast.  If  this  is  done  too  soon,  re- 
intoxication  occurs.  A  too  prolonged  starvation  adds 
the  danger  of  inanition. 

A  sustaining  diet  should  be  reached  in  eight  to  ten  days 
{2)2  calories  per  pound),  after  which  the  child  can  be  put 
on  the  breast  five  times  daily.  Weigh  infant  before  and 
after  feeding,  if  placed  at  the  breast.  If  the  elevation  of 
temperature  returns,  except  in  the  presence  of  infection, 
cut  down  the  food.  The  gain  in  weight  is  very  slow  in 
the  stage  of  repair  on  human  milk,  due  to  the  low  pro- 
tein and  salt  content. 

Cozv's  Milk.  For  the  first  few  days  after  the  hunger 
day,  a  food  low  in  fat  and  sugar  should  be  fed,  because 
of  the  lowered  tolerance.  One-half  skim  milk  or  butter- 
milk, boiled  or  citrated  without  sugar,  will  answer,  but 
should  be  fed  in  small  quantities,  10  times  5  mils  daily, 
then  10  times  10  mils.  On  this  low  diet  weight  loss  and 
temperature  will  usually  stop.  There  is,  however,  again 
great  danger  from  underfeeding  too  long,  so  that  these 
infants  ofifer  every  indication  for  our  best  judgment.  At 
all  times  plenty  of  indifferent  fluids  should  be  adminis- 
tered between  feedings.  After  ten  to  fourteen  days,  32 
'Calories  per  pound  may  be  fed.  Less  rapid  increase  than 
in  human  milk  feeding  should  be  the  rule.  Older  infants 
can  be  given  gruels  in  their  milk.  Recurrence  of  dyspep- 
sia is  an  indication  for  return  to  indifferent  foods.  With 
a  second  recurrence  breast  milk  is  absolutely  indicated. 


236  INFANT   FEEDING. 

Return  to  carbohydrates  should  be  made  with  great  care, 
adding  1  per  cent,  to  the  food  mixture,  and  increasing  to 
5  per  cent,  with  continued  improvements.  The  maltose- 
dextrin  compounds  are  best  for  this  purpose. 

Albumin  milk  is  indicated  in  this  condition,  and  the 
following  is  a  good  working  rule  for  its  use  in  these 
cases :  First  day,  tea.  Second  day,  10  times  5  mils  albu- 
min milk  with  tea  ad  libitum.  Increase  50  mils  daily 
until  stools  are  good ;  then  further  increase  100  mils  daily 
until  180  to  200  mils  are  given  for  each  kilogram  of  body 
weight  (3  ounces  per  pound).  After  the  stools  are  firm, 
add  sugar  to  the  food,  and  increase  gradually  to  4  per 
cent.  Dextrin-maltose  compounds  are  best.  In  intoxi- 
cation we  have  obtained  better  results  by  at  first  feeding 
albumin  milk  without  sugar  addition,  but  containing  1 
per  cent,  of  flour  (flour  ball).  After  six  to  eight  weeks 
an  ordinary  milk  mixture  may  be  fed.  Feedings  can 
now  be  reduced  to  five  or  six  daily.  Never  feed  over 
1000  mils  a  day  of  albumin  milk.  Before  this  amount 
can  be  digested  we  have  usually  reached  the  point  where 
sugar  can  be  added  to  meet  the  caloric  needs  of  the 
infant. 


CHAPTER    VII. 

MIXED    FORMS    OF    NUTRITIONAL 
DISTURBANCES. 

Disturbed  metabolic  balance  is  frequently  associated 
with  dyspeptic  symptoms.  Again,  these  may  show  signs 
of  intoxication.  Decomposition  is  the  form  most  subject 
to  complication. 

Treatment.  Disturbed  metabolic  balance  with  dyspep- 
tic symptoms  is  to  be  treated  as  dyspepsia,  by  reducing 
the  diet.  In  dyspeptics  with  signs  of  intoxication  employ 
hunger  diet,  etc. 

Decomposition  complicated  by  intoxication  is  the 
severest  combination,  but  can  be  recognized,  if  careful 
consideration  is  given  to  the  history  and  to  the  infant's 
general  condition.  The  greatest  danger  hes  in  the  fact 
that  in  the  former  we  must  nourish,  in  the  latter  starve. 
With  only  a  short  hunger  period  (six  hours)  either 
human  or  albumin  milk  should  be  given  in  small  quanti- 
ties, 10  times  5  mils,  and  increased  by  50  mils  daily  under 
control  of  the  clinical  symptoms.  After  8  to  10  days  of 
the  above,  the  infant  can  usually  be  put  to  the  breast  five 
times  daily.  The  weight  may  remain  stationary,  and  one 
must  judge  by  the  stools  and  general  condition  as  to  the 
addition  of  further  foods.  With  albumin  milk,  after 
three  to  four  days,  the  weight  becomes  stationary,  and 
the  stools  of  a  fat-soap  character;  then  gradually  some 
malt-sugar  may  be  added. 

In  nutritional  disturbances  associated  with  an  infection 
an  early  diagnosis  is  most  important,  otherwise  there  is 
the  danger  of  carrying  the  underfeeding  to  the  point  of 
lowering  the  resistance  of  the  child  beyond  repair. 

(237) 


CHAPTER   VIII. 

NUTRITIONAL    DISTURBANCES    DUE   TO 
INSUFFICIENT    FOOD. 

This  group  of  cases  may  be  divided  into  two  classes : 
(1)   Quantitative  inanition,   (2)   qualitative  inanition. 

1.  Quantitative  Inanition.  The  cases  of  this  class 
include  those  infants  receiving  a  diet  containing  a  proper 
proportion  of  the  necessary  food  ingredients,  but  of  in- 
sufficient caloric  value.  (Too  little  of  a  proper  food.) 
These  must  again  be  divided  into  two  groups : 

(a)  Normal   infants   quantitatively  underfed. 

In  breast-fed  infants  this  group  is  more  common  than 
in  artificially  fed.  And  while  in  the  artificially  fed  such 
cases  are  occasionally  seen,  this  is  a  far  less  frequent 
condition  than  overfeeding.  Because  in  the  normal  in- 
fant hunger  is  manifested  by  crying,  restlessness,  loss 
of  weight  and  associated  constipation,  which  fortunately 
in  most  instances  leads  to  a  proper  interpretation,  result- 
ing in  increase  of  the  diet. 

(b)  Infants  suffering  from  nutritional  disturbances, 

quantitatively  underfed. 
These  cases  are  the  ones  which  so  frequently  suffer 
from  quantitative  inanition,  due  to  the  fact  that  the  fever, 
vomiting,  and  diarrhea  offer  every  indication  for  a  re- 
duction in  diet,  or  a  starvation  diet.  While  this  leads  to 
an  improvement  in  the  general  symptoms,  the  remaining 
hunger  stool,  because  of  its  greenish-brown  color  and 
excess  of  mucus,  is  not  uncommonly  interpreted  as  a 
diarrheal  stool,  leading  to  prolonged  starvation,  and  not 
infrequently  repeated  catharsis. 
(238) 


DISTURBANCES  DUE  TO  INSUFFICIENT  FOOD.     239 

The  similarity  of  the  grave  hunger  conditions  follow- 
ing repeated  starvation  to  decomposition  is  very  striking. 
This  is  easy  to  understand,  because  the  symptoms  of  de- 
composition are  after  all  due  to  a  condition  of  inanition 
caused  by  deficient  absorption  of  food,  and  by  loss  of  the 
body  substance.  In  the  beginning,  and  for  a  longer  time 
thereafter,  the  inanition  differs  from  decomposition  in 
the  reaction  to  the  increase  of  the  food,  which  in  simple 
inanition  is  followed  by  gain  in  weight,  in  decomposition 
frequently  by  loss  of  weight.  Finally,  however,  even  in 
the  child  suffering  from  simple  inanition  the  weakening 
of  the  organism  reaches  the  stage  in  which  there  is  a 
decrease  of  tolerance  to  food. 

Treatment.  Propliylaxis.  Repeated  hunger  days 
and  long-continued  underfeeding  should  be  instituted 
only  upon  definite  indications,  the  sudden  decrease  in  the 
food  leading  regularly  to  weight  loss  and  lowered  food 
tolerance. 

An  initial  cathartic  is  frequently  indicated,  while  re- 
peated catharsis  is  harmful. 

The  diet  should  be  as  rapidly  increased  as  the  infant's 
condition  will  tolerate.  It  should  be  carefully  selected  to 
meet  the  requirements  of  the  individual  infant. 

While  in  mild  cases  a  properly  selected  diet  leads  to 
rapid  recovery  and  gain  in  weight,  in  the  severe  cases 
bordering  on  decomposition,  we  not  infrequently  see  a 
paradoxical  reaction  to  food,  necessitating  feeding  as 
described  under  the  chapter  on  Decomposition. 

In  every  case  the  infant's  tolerance  to  food  should  be 
carefully  studied,  and  increases  made  only  as  tolerance 
permits. 

Hunger  stools-  are  rapidly  replaced  by  those  of  normal 
consistency  in  the  presence  of  a  proper  diet. 


240  INFANT   FEEDING. 

2.  Qualitative  Inanition.  As  qualitative  inanition 
are  designated  those  forms  of  nutritional  disturbances 
which  are  due  to  the  lack  or  insufficiency  of  one  or  more 
indispensable  food  substances  or  constituents  of  the 
food.  The  quaHtative  inanition  is  very  frequently  asso- 
ciated with  quantitative  inanition. 

Flour  Injury.  From  among  these  conditions  of  in- 
anition the  most  frequent  in  the  infant  is  the  flour  in- 
jury (Alehlnahrschaden — Czerny  and  Keller). 

Etiology.  The  condition  follows  feeding-  with  a  diet 
composed  largely  of  cereals  or  cereal  waters,  as  is  fre- 
quently seen  when  these  are  used  to  replace  milk  mix- 
tures which  have  been  poorly  taken  (dyspepsia,  etc.). 
It  is  therefore  due  to  continued  feeding  of  flour  gruels, 
either  without  milk  or  a  diet  too  low  in  milk  content. 
Whether  simple  flour  or  baby  foods,  dextrinized  or  not 
are  used,  the  result  is  the  same.  Although  the  flour  in 
its  digestion  is  changed  to  sugar,  the  effects  are  not  those 
of  excessive  sugar  diet  (acute),  but  only  leads  to  acute 
symptoms  after  the  organism  has  been  generally  im- 
paired by  the  long  use  of  the  one-sided  diet. 

Pathogenesis  and  Metabolism.  The  disturbance  of 
the  organism  which  develops  on  one-sided  flour  feeding 
is  to  be  regarded  as  qualitative  inanition,  being  due  to 
the  lack  of  important  tissue-building  substances  (fat, 
proteins,  salts),  and  the  resulting  improper  formation  of 
the  body  tissues. 

Steinitz  and  Weigert  found  in  animals  that  a  flour  diet 
led  to  an  abnormal  chemical  composition  of  the  organ- 
ism. The  body  became  richer  in  water  and  fat  than  nor- 
mal, and  this  excess  of  w^ater  reduces  the  natural  im- 
munity. The  oedema  indicates  a  disturbance  in  the  salt 
balance  between  the  tissues  and  body  fluids. 


DISTURBANCES  DUE  TO  INSUFFICIENT  FOOD.    241 

In  many  cases,  also,  the  caloric  intake  may  be  insuffi- 
cient, so  that  quantitative  inanition  complicates  the  pic- 
ture. The  accumulation  of  large  quantities  of  water 
which  occurs  when  large  quantities  of  flour  are  fed  in 
presence  of  salts  results  in  fluctuations  in  weight. 

Rapidity  of  development  depends  on  the  following 
factors : 

1.  Age.    The  younger  the  child,  the  quicker  the  effects. 

2.  The  more  the  flour  outweighs  the  other  ingredients 
of  the  diet. 

Symptoms.  They  may  assume  any  form  of  nutri- 
tional disturbances.  In  many  cases  apparent  symptoms 
of  disease  are  lacking  for  a  long  time  in  spite  of  the 
improper  diet.  The  infant  may  even  apparently  thrive 
well,  since  (due  to  the  great  water-binding  property  of 
carbohydrates)  considerable,  gains  in  weight  may  occur. 
The  appearance  of  the  child  is  good,  and  fat  cushion 
abundant.  T^ven  at  this  time,  however,  frequently  some 
anomalies  are  observed :  the  musculature  may  be  slightly 
hypertonic,  the  appearance  may  be  pasty,  suggesting  a 
water-soaked  sponge.  Not  infrequently  by  careful  exam- 
ination nervous  irritability  (latent  tetany)  may  be  de- 
tected. This  is  followed  by  development  of  grave  symp- 
toms of  typical  flour  injury,  which  may  assume  variable 
appearance,  according  to  whether  the  flour  is  given  alone 
or  combined  with  some  other  food. 

Flour  has  the  property  of  causing  the  body  to  take  on 
weight  by  water  absorption.  This  is  especially  true  if 
the  infant  was  previously  healthy,  and  may  be  mislead- 
ing. In  infants  suffering  from  nutritional  disturbances 
the  picture  develops  more  rapidly,  especially  upon  in- 
auguration of  repeated  starvation  diet.  Finally,  how- 
ever, both  these  groups  of  infants  present  the  picture  of 

16 


242  INFANT   FEEDING. 

an  inanition — that  is,  the  atrophic  stadium,  which  cannot 
be  distinguished  from  a  decomposition  clinically.  They 
are  subject  to  rapid  weight  and  water  losses,  showing  the 
loose  binding  of  the  water  in  the  tissues. 

CEdema  may  complicate  the  picture,  especially  where 
the  flour  is  given  in  a  salt-rich  diet  as  bouillon,  milk,  etc., 
and  the  oedema  may  resemble  that  of  a  nephritic  patient 
(urine  is  usually  negative). 

The  natural  immunity  in  these  hydremic  conditions  is 
greatly  reduced,  and  the  children  are  subject  to  furun- 
culosis,  otitis,  ^nd  infections  of  the  respiratory  and  diges- 
tive tracts,  all  of  which  give  a  bad  prognosis. 

Hypertonia  is  very  common,  with  a  characteristic  mus- 
cular rigidity,  resulting  in  stiffening  of  extremities,  opis- 
thotonos, etc.,  and  it  is  often  difficult  to  differentiate 
them  from  cases  of  spastic  cerebral  paralysis  and  chronic 
tetany,  from  which  latter  these  infants  often  suffer. 
The  history  of  nen^e  irritability  must  be  used  as  a  point 
of  differentiation. 

Hypertonic  form  has  also  been  described,  the  chief 
symptom  of  which  is  the  rigidity  of  the  muscles.  This 
hypertonicity  may  occasionally  assume  such  proportions 
that  the  limbs  and  the  entire  body  may  become  rigid. 
But  this  condition  is  not  exclusively  caused  by  flour  in- 
jury, but  may  be  seen  also  in  other  nutritional  dis- 
turbances. 

Stools.  Often  the  stools  are  good  for  a  long  time, 
but  sooner  or  later  in  all  cases  acute  intestinal  symptoms 
develop.  More  characteristic,  after  continued  feeding  on 
a  one-sided  flour  diet  are  soft,  mushy,  loose  stools,  which 
are  frequent,  and  vary  in  color  from  brown  to  yellow.  A 
further  characteristic  is  a  tendency  to  fermentation,  with 
the  formation  of  acids  and  gas,  which  tend  to  irritate  the 


DISTURBANCES  DUE  TO  INSUFFICIENT  FOOD.    243 

Inittocks.  The  small,  dark-brown  stools,  composed 
mainly  of  mucus  (hunger  stools),  are  not  infrequently 
seen,  and  are  of  especial  significance,  because  they  are 
often  misinterpreted  as  dyspeptic  stools. 

Diagnosis.  The  feeding  history  is  of  the  utmost 
importance.  Hypertonia  and  oedema  should  lead  to  sus- 
picion. Presence  of  excessive  fermentation  or  of  "hun- 
ger stool." 

Prognosis.  The  younger  the  infant  and  the  longer 
the  unsuitable  diet  has  been  continued,  the  worse  is  the 
prognosis.  The  high  mortality  in  this  condition  is  due 
not  so  much  to  the  nutritional  disturbance  itself,  but 
more  so  to  unavoidably  complicating  infections.  Tetanies 
and  convulsions  due  to  them  are  also  grave  complications. 

Prophylaxis.  The  development  of  a  primary  flour 
injury  is  prevented  by  ordering  proper  diet.  In  using  the 
flour  diet  for  therapeutic  purposes  in  the  treatment  of 
dyspepsia,  especially  when  repeated  starvation  is  in- 
augurated, the  danger  of  development  of  the  flour  injury 
must  be  kept  in  mind,  and  the  one-sided  diet  must  not 
be  continued  longer  than  several  days. 

Treatment.  1.  Human  Milk.  In  young  infants  and 
also  in  all  severe  cases,  feeding  with  human  milk  offers 
the  best  hope  for  the  cure  of  the  condition.  It  is  abso- 
lutely indicated  (1)  before  the  third  month,  (2)  in  evi- 
dence  of   decomposition. 

Begin  with  200  to  300  mils  daily,  as  in  decomposition, 
and  continue,  even  with  weight  loss  and  development  of 
dyspeptic  symptoms.  Increase  the  amount  steadily. 
Even  with  human  milk  the  course  will  be  slow,  if  the 
condition  is  well  advanced. 

2.  Artificial  Feeding.  One-half  to  two-thirds  skim 
or  whole  milk  plus  water  in  feedings  of  10  times  10  mils 


244  INFANT   FEEDING. 

with  water  or  tea  ad  libitum.  Continue,  even  with  weight 
loss,  which  is  the  rule,  unless  the  stools  are  dyspeptic.  It 
may  often  be  of  advantage  to  make  the  loss  slower  by 
addition  of  some  flour  or  maltose-dextrin  preparations  to 
the  milk  mixture.  Albumin  milk  and  buttermilk  mix- 
tures are  often  taken  to  better  advantage  than  whole 
milk  mixtures.     If  they  fail,  human  milk  must  be  given. 

If  stools  retain  fat-soap  character  after  10  to  14  days, 
the  diet  may  be  more  rapidly  increased. 

Course  is  often  interrupted  by  weight  drops  and  in- 
fections. 

In  very  severe  cases  in  which  symptoms  of  decomposi- 
tion are  present,  same  treatment  as  in  decomposition 
should  be  instituted. 


CHAPTER    IX. 

INFECTION    AND    NUTRITION. 

The  intimate  relation  between  infection  and  nutrition 
may  be  made  clear  by  considering  the  subject  under  three 
headings : 

1.  The  susceptibility  to  infections  as  influenced  by 
previous  diet  and  the  state  of  nutrition. 

2.  The  course  of  infections  as  affected  by  diet  and  the 
state  of  nutrition. 

3.  The  influence  of  infection  upon  nutritional  proc- 
esses. 

(a)  Parenteral  infections. 

(b)  Enteral  infections. 

1.  Susceptibility  Influenced  by  Nutrition. 

The  previous  diet  and  the  state  of  nutrition  being  the 
same,  there  are  marked  individual  differences  in  the  sus- 
ceptibility to  infection.  Among  the  breast-fed  infants 
there  are  on  one  hand  infants  who  remain  free  from  any 
infection,  even  under  very  unfavorable  external  condi- 
tions, while  on  the  other  hand  there  are  breast-fed  infants 
who  under  favorable  conditions  often  contract  an  infec- 
tion. This  points  to  congenital  differences  based  on  the 
difference  in  the  constitution  of  the  individual.  As  a 
rule,  the  lowering  of  immunity  is  not  the  only  sign  of 
inferior  constitution  in  these  infants,  but  they  show  a 
number  of  other  symptoms  of  a  constitutional  anomaly, 
such  as  exudative  and  neuropathic  diathesis.  •  In  this 
group  of  infants  the  susceptibility  to  infection  becomes 
even  more  striking  when  they  are  put  on  artificial  feeding, 

(245) 


246  IXFAXT    FEEDIXG. 

and  especially  when  the  diet  is  improper.  In  infants 
with  constitutional  anomalies  one  is  justified  in  thinking 
of  an  abnormal  composition  of  the  tissues  and  of  the 
body  fluids,  both  the  latter  factors  in  themselves  leading 
to  a  lowering  of  immunity. 

The  natural  immunity  of  the  healthy  breast-fed  infant 
affords  the  best  example  of  the  importance  of  the  diet 
in  the  establishment  of  resistance  to  infection. 

In  the  artificially  fed  infants  the  increased  susceptibil- 
ity to  infection  is  usually  based  on  nutritional  disturb- 
ances, which,  however,  may  be  so  slight  as  to  escape 
recognition.  However,  when  a  careful  study  is  made 
of  the  feeding  history  the  cause  can  usually  be  demon- 
strated in  a  poorly  balanced  diet,  more  commonly  one 
excessive  in  carbohydrates  and  fats,  which  result  in  an 
abnormal  composition  of  the  tissues  (see  ^Nutritional 
Disturbances).  Those  modes  of  feeding  which  cause 
normal  tissue  chemistry  diminish  susceptibility,  while 
every  form  of  feeding  which  unfavorably  influences 
metabolism  increases  susceptibility  to  infection. 

In  the  artificially  fed  infants  these  facts  offer  valuable 
therapeutic  suggestions,  and  should  lead  one  to  avoid 
overfeeding  as  a  whole  as  well  as  of  the  individual  con- 
stituents of  the  diet,  and  the  early  administration  of  the 
mixed  diet. 

The  susceptibility  to  infection  is  increased  by  every 
nutritional  disturbance.  This  apphes  to  the  simple  and 
seeminglv  harn^less  digestive  disturbances,  as  well  as  to 
the  more  severe  forms   (decomposition,  intoxication). 

2.  Course  of  Infections  Influenced  by  Nutrition. 

The  course  of  the  infection  is  essentially  influenced  by 
constitution,  age,  hygienic  conditions,  mode  of   feeding, 


INFECTION    AND    NUTRITION.  247 

and  the  state  of  nutrition.  The  premature  and  the  very 
young  react  poorly  to  infections.  Gastro-intestinal,  pul- 
monary and  septic  infections  of  the  newborn  have  usu- 
ally an  unfavorable  course,  especially  in  the  artificially 
fed  infants.  Infants  suffering  from  constitutional  anom- 
alies are  less  likely  to  react  favorably  than  normal, 
healthy  infants.  In  all  infants  suffering  from  exudative 
or  neuropathic  diathesis  even  slight  infections  should  be 
given  serious  consideration. 

Nutritional  disturbances  have  a  direct  influence  on  the 
prognosis  of  all  forms  of  infections.  This  is  more  espe- 
cially true  of  the  infections  of  the  respiratory  passages, 
in  which  a  simple  rhinitis  or  pharyngitis  may  readily  be 
complicated  by  pneumonia  and  severe  gastro-intestinal 
complications,  but  also  true  of  the  simple  skin  infections, 
which  may  rapidly  take  a  serious  course  resulting  in 
sepsis. 

The  institution  of  a  proper  diet  is  of  primary  impor- 
tance in  all  cases  of  infections. 

Feeding  with  human  milk  is  the  treatment  of  choice. 
If  this  is  not  obtainable,  and  it  is  necessary  to  feed  arti- 
ficial food  mixtures,  they  must  of  necessity  be  well  bal- 
anced, and  excesses  of  carbohydrates  are  to  be  avoided. 
Whenever  possible,  a  mixed  diet  should  be  instituted. 

3.  Infection  Influencing  Nutrition. 

Infection  may  produce  any  form  of  nutritional  dis- 
turbance, from  the  slightest  forms  to  the  most  severe 
forms  of  decomposition  and  intoxication.  One  may  al- 
most say  that,  for  the  production  of  nutritional  disturb- 
ances, infections  are  to  be  ranked  as  of  equal  importance 
with  dietetic  errors. 


248 


INFANT   FEEDING. 


Although  the  course  of  alimentary  nutritional  disturb- 
ances is  very  similar  to  that  of  nutritional  disturbances 
due  to  infection,  still  there  are  important  differences  that 
must  be  kept  constantly  in  mind  in  order  to  avoid  fail- 
ures in  the  treatment.  The  following  table  briefly  sum- 
marizes the  most  important  differences  between  the  two 
forms  of  nutritional  disturbances : 


Nutritional    Disturbances    due    to 
Alimentation. 

History  of  dietetic  errors,  espe- 
cially high  sugar  diet. 

Appearance  of  intoxication 
only  on  a  diet  rich  in  whey 
and  sugar. 

Disintoxication  of  toxic  states 
(fever,  nervous  symptoms, 
etc.)  by  withdrawal  of  food. 

Improvement  in  general  con- 
dition, and  especially  of  diar- 
rhea, on  correction  of  the 
diet,  especially  by  reduction 
of  whey  and  sugar  com- 
ponent part. 

Progressive  narrowing  of  food 
tolerance  in  untreated  cases. 


Nutritional    Disturbances    due   to 
Infection. 

Acute  disturbances  not  so 
much  dependent  on  the 
nature  of  the  diet. 

Intoxication  occurs  also  on  diet 
low  in  whey  and  sugar. 

Toxic  states  continue  or  even 
become  worse  in  spite  of 
withdrawal  of  food. 

Persistence  of  diarrhea  after 
similar  change  of  diet,  at 
least  in  a  number  of  cases. 


Spontaneous  increase  of  toler- 
ance without  special  dietetic 
treatment  after  the  infection 
passes  over  (in  majority  of 
cases,  not  always). 


(A)   Parenteral  Infections. 

Etiology.  It  has  already  been  pointed  out  with 
what  great  frequency  infants  and  children  suffering  from 
nutritional  disturbances  are  subject  to  secondary  infec- 
tion. The  most  frequent  of  these  are  those  of  the  skin, 
respiratory,  gastro-intestinal,  and  genito-urinary  tracts, 
ears  and  general  septic  infections. 


INFECTION   AND    NUTRITION.  249 

In  contradistinction  to  this,  infections,  such  as  ''colds," 
tonsillitis,  pneumonia,  otitis,  cystitis,  pyelitis,  which  are 
accompanied  by  lowered  food  tolerance,  very  frequently 
result  in  secondary  nutritional  disturbances.  They  are 
likely  to  run  a  more  severe  course  than  the  primary 
nutritional  disturbances. 

The  common  occurrence  of  the  ''summer  diarrheas" 
leads  us  to  search  for  a  relationship  between  heat  and  the 
nutritional  disturbances  as  seen  in  summer.  This  rela- 
tionship has  already  been  discussed  under  the  chapter  on 
Intoxication.  However,  it  may  be  well  to  briefly  enumer- 
ate the  factors  which  are  important  in  the  causation  of 
these  nutritional  disturbances.  High  temperatures  cause 
systemic  depression,  and  directly  influence  all  of  the  body 
functions.  Less  food  is  required  in  hot  weather,  and 
therefore  the  previous  diet  may  be  considered  excessive 
in  many  instances.  Bacterial  action  on  the  milk,  and  the 
subsequent  production  of  toxic  bodies,  is  a  factor  of  pri- 
mary importance.  An  excessive  retention  of  heat  by 
overdressing  during  the  summer  months  has  been  proven 
to  be  a  contributing  factor  by  McClure  and  Sauer.* 

A  study  of  the  cases  of  diarrheas  in  the  wards  of 
Sarah  Morris  Hospital  by  Gerstley  and  Day  during  the 
course  of  two  summers  showed  that  most  of  our  intes- 
tinal cases  were  secondary  to  parenteral  infections,  and 
not  primary  intestinal  infections,  as  described  by  Ken- 
dall and  Day  in  their  investigations  of  the  Boston  epi- 
demics. This  could  in  greater  part  at  least  be  accounted 
for  by  the  fact  that  all  of  the  milk  fed  to  our  infants  was 
either  pasteurized  or  boiled,  while  in  the  eastern  cities 
considerable  raw  milk  was  fed. 


*  Sauer,  Am.  Jour.  Dis.  Child,  1915,  ix,  490. 


250  IXFAXT   FEEDING. 

Symptoms.  By  careful  clinical  observation  and  ex- 
perimental investigation  L.  F.  Meyer  has  shown  that  in- 
fection may  produce  the  following  changes : 

1.  Diminution  in  the  gain  in  weight  without  any  acute 
symptoms  on  the  part  of  the  gastro-intestinal  canal  dur- 
ing or  after  the  infection. 

2.  Loss  of  weight  and  changes  in  the  stools  cor- 
responding to  the  acute  nutritional  disturbances. 

(a)  Acute  disturbances  of  the  nature  of  dyspepsia 

beginning  with  the  infection  and  disappear- 
ing after  the  infection  has  been  overcome. 

(b)  Acute  disturbances  which  begin  wnth  the  infec- 

tion, but  remain  even  after  the  infection  is 
overcome,  under  certain  conditions  for  weeks 
(chronic  dyspepsia). 

(c)  Grave   nutritional   disturbances  beginning  Avith 

the   infection,  but    soon   becoming  the   most 

prominent    in  the    clinical    picture,    with    or 

without  toxic  symptoms  (intoxication,  de- 
composition). 

Diagnosis.  Alimentary  intoxication  is  usually  easily 
recognized  by  the  nervous  symptoms,  toxic  expression, 
pauseless  respiration,  and  marked  drops  in  the  weight 
curve.  In  intoxication,  temporary  complete  withdrawal 
of  food  in  the  absence  of  severe  infection  results  in  dis- 
intoxication. This  is  known  as  therapeutic  dietetic  test. 
In  parenteral  infections  this  is  not  the  case,  and  starva- 
tion only  leads  to  further  reduction  ,of  resisting  power, 
and  therefore  should  not  be  long  continued. 

It  is  necessary  to  avoid  the  mistake  of  overestimating 
the  intestinal  condition  for  which  in  many  cases  the 
physician  is  called,  and  thereby  failure  to  recognize  the 


INFECTION    AND    NUTRITION. 


251 


252  INFANT   FEEDING. 

underlying  infection,  such  as  "cold,"  bronchitis,  pneu- 
monia, pyelitis,  etc.,  as  a  fundamental  factor. 

Treatment.  For  treatment  practically  the  most  im- 
portant characteristic  of  nutritional  disturbances  due  to 
infection  is  the  spontaneous  rise  of  food  tolerance  after 
the  cure  of  the  infection. 

The  primar}^  infection  calls  for  foremost  considera- 
tion, and  its  treatment  must  necessarily  vary  according 
to  its  nature.  The  intestinal  condition,  on  the  other  hand, 
if  mild  in  nature,  frequently  calls  for  little  treatment  in 
these  infants,  more  especially  because  in  the  presence  of 
fever  there  is  a  tendency  to  reduce  the  intake  of  food, 
which  in  itself  is  sufficient  to  correct  the  intestinal  dis- 
turbance. Further,  with  the  improvement  of  the  infec- 
tion the  appetite  returns,  and  the  infant  will  demand  in- 
creased food. 

Where  it  is  possible  to  keep  up  the  baby's  nutrition  by 
the  proper  administration  of  food  during  the  course  of  an 
infection,  such  children  may  be  subject  to  little  or  no 
weight  loss.  In  more  serious  cases  the  food  must  be  re- 
duced both  qualitatively  and  quantitatively,  more  espe- 
cially the  sugars  and  the  fats.  However,  in  order  to 
avoid  catastrophes,  long-continued  underfeeding  or  star- 
vation must  of  necessity  be  avoided,  since  this  treatment, 
causing  insufficient  nutrition  of  the  body-cells,  would  de- 
crease the  resistance  of  the  infant. 

The  safest  plan  is  to  administer  in  place  of  carbohy- 
drate- and  whey-rich  mixtures,  which,  as  has  often  been 
pointed  out,  easily  lead  to  acute  digestive  disturbances, 
mixtures  high  in  proteins  and  low  in  sugar  and  whey. 
Human  milk,  albumin  milk,  and  skim  and  buttermilk 
mixtures,  with  small  amount  of  sugar  only  are  to  be 
used.      In   grave  nutritional   disturbances,   with   sudden 


INFECTION    AND   NUTRITION.  253 

losses  of  weight  and  toxic  symptoms,  complete  with- 
drawal of  food  cannot  be  avoided. 

In  young  and  weak  infants,  as  previously  stated,  breast 
milk  may  be  imperative.  In  older  infants,  and  those  less 
severely  infected,  albumin  milk,  with  2  or  3  per  cent,  of 
sugar  addition,  or  buttermilk  and  skim  milk  mixtures  are 
frequently  well  taken.  In  all  cases  inanition  must  be 
avoided  by  keeping  the  child  on  a  sustaining  diet  of  70 
calories  per  kilogram,  or  an  amount  above  this. 

The  type  of  infants  who  have  been  improperly  fed, 
more  especially  those  who  have  been  raised  on  con- 
densed milk  or  other  foods  containing  a  fninimum  of 
fat  and  protein,  but  an  excess  of  carbohydrates,  offer 
greater  difficulties,  because  they  possess  a  limited  im- 
munity to  all  forms  of  infection,  beside  reacting  poorly 
to  changes  in  their  diet  during  illness.  They  also  react 
very  poorly  to  starvation,  rapidly  passing  into  a  state  of 
decomposition.  The  treatment  in  these  cases  should  fol- 
low that  outlined  for  milder  forms  of  decomposition. 

To  repeat,  under  all,  circumstances  food  should  be  re- 
stricted as  little  as  possible. 

The  two  most  important  symptoms  calling  for  treat- 
ment in  the  course  of  parenteral  infections  are  (1)  vomit- 
ing and  (2)  refusal  of  food. 

If  temporary  reduction  in  food  does  not  relieve  vomit- 
ing, it  may  be  necessary  to  resort  to  gastric  lavage  which 
is  best  performed  with  1  per  cent,  sodium  bicarbonate 
solution,  allowing  2  or  3  ounces  of  the  solution  to  re- 
main in  the  stomach,  with  the  administration  of  slightly 
sweetened  tea  or  cereal  waters  ad  libitum,  as  retained. 
Prolonged  starvation  must  be  avoided. 

We  have  found  chymogen  milk  fed  in  small  quantities 
at  two-  to  three-  hour  intervals  especially  suitable  for 


254  INFANT   FEEDING. 

these  cases.     This  is  probably  due  to  the  fact  that  the 
casein  is  precipitated  in  a  flocculent  form. 

Refusal  of  food  which  is  commonly  experienced  in 
these  infants  calls  for  catheter  feeding  (see  chapter  on 
Premature  Infants). 

(B)  Enteral  Infections. 

Etiology.  Besides  the  alimentary  nutritional  dis- 
turbances proper,  there  are  in  childhood,  and  especially 
in  infancy,  numerous  diseases  that  have  to  be  regarded 
as  true  infections  of  the  digestive  canal,  due  to  invasion 
of  pathogenic  bacteria,  or  increased  and  changed  activity 
of  the  bacteria  normally  present.  In  many  cases  infective 
material  is  introduced  by  food,  and  especially  by  the 
milk,  in  which  the  micro-organisms  are  present,  being  de- 
rived from  the  diseased  cattle  that  furnishes  the  milk 
(Streptococcus  from  inflamed  udders.  Bacillus  coli  from 
feces)  or  bacteria  pathogenic  for  the  human  may  find 
their  way  into  the  milk  in  transportation  from  the  place 
of  production  to  the  place  of  consumption.  Besides  this, 
water  or  contaminated  foods  other  than  milk  may  be  the 
medium  through  which  infection  takes  place. 

There  are  numerous  cases  of  transmission  by  contact. 
These  are  most  commonly  seen  in  the  epidemic  appear- 
ance of  gastro-enteritis  in  institutions  for  small  children 
and  infants.  A  small,  but  typical  epidemic  is  reported 
by  Smillie*  who  has  observed  it  during  his  study  of  epi- 
demiology of  bacillary  dysentery.  Four  babies  developed 
bacillary  dysentery  in  the  wards  of  the  hospital,  each  of 
them  having  been  admitted  with  quite  a  different  diag- 
nosis, and  their  stools  having  been  negative  on  admis- 


*  Smillie,  Am.  Jour.  Dis.  Child.,  1917,  xiii,  337. 


INFECTION    AND    NUTRITION.,  255 

sion.  Each  developed  the  disease  seven  to  ten  days  after 
admission,  and  in  no  instance  did  the  infant  come  from 
an  infected  home  or  neighborhood. 

The  environment  of  the  infant,  and  especially  lack  of 
proper  cleanliness  generally,  and  in  preparation  of  food 
especially,  are  very  important  factors,  which  make  the 
enteral  infection  possible. 

Parenteral  infections  are  often  followed  by  enteral  in- 
fections, and  this  is  especially  true  of  infections  of  the 
respiratory  tract  which  often  lead  to  enteral  infections 
producing  what  has  been  called  "bronchoenterocatarrh."' 

The  most  important  clinical  condition  among  the  en- 
teral infections  is  inflammation  of  the  intestinal  mucosa 
(enteritis),  brought  about  by  a  variety  of  bacteria,  and 
accompanied  by  slimy,  purulent,  and  bloody  evacuations 
and  tenesmus.  The  causative  bacteria  may  be  Strepto- 
cocci, Bacillus  typhosus,  B.  paratyphosus,  B.  coli,  B.  dys- 
enterise,  B.  pyocyaneus,  B.  aerogenes  capsulatus  (gas 
bacillus),  and  B.  lactis  aerogenes. 

Kendall  and  Day,  making  a  careful  study  of  the  epi- 
demics of  summer  diarrhea  in  Boston,  found  that  during 
the  year  1910  the  epidemic  was  mainly  due  to  dysentery 
bacillus,  fully  7^  per  cent,  of  52  cases  being  due  to  these 
organisms.  Streptococci  were  also  present  in  about  60 
per  cent,  of  the  dysentery  cases,  probably  as  secondary  or 
terminal  invaders.  The  summer  of  1911  was  noteworthy 
as  a  "streptococcus"  year ;  54  per  cent,  of  146  cases 
studied  harbored  large  numbers  of  these  organisms.  The 
year  of  1912  was  a  ''gas  bacillus"  year,  these  organisms 
appearing  in  unusually  large  numbers  in  39  per  cent,  of 
135  cases  examined.  Each  of  the  above  types  was  found 
each  year,  but  the  striking  feature  is  the  shifting  of  the 
dominant   organism   from  year   to  year.     Kendall  con- 


256  INFANT   FEEDING. 

eludes  that,  bacteriologieally  eonsidered,  these  cases  are 
of  varied  etiology,  caused  by  organisms  of  very  unlike 
characteristics. 

In  contrast  to  this,  Gerstley  and  Day  studied  the  sum- 
mer diarrheas  at  the  Sarah  Morris  Hospital  for  Children 
(Chicago)  during  the  course  of  two  summers,  and  found 
that  most  of  them  were  secondary  to  parenteral  infections 
(see  p.  249).  Day  worked  both  in  Boston  and  Chicago 
cases,  and  therefore  the  error  could  not  have  been  one 
of  technic.  The  difference  was  probably  due  to  use  of 
boiled  milk  in  Chicago,  and  unboiled  milk  in  the  East, 

Pathology.  To  the  invasion  of  pathogenic  bacteria 
the  digestive  canal  reacts  by  inflammation  of  the  intes- 
tines (enteritis).  The  large  intestine  is  always  more 
affected,  while  in  the  small  intestine  the  pathological 
process,  as  a  rule,  is  limited  to  its  lower  portion.  How- 
ever, in  cases  secondary  to  infections  of  the  nose  and 
throat,  even  the  gastric  mucosa  may  be  involved.  Mes- 
enteric lymph-glands  are  swollen.  In  some  cases  the 
bacteria  invade  the  deeper  organs  also,  and  may  be  cul- 
tivated from  the  spleen  and  the  gall-bladder.  Liver  and 
kidneys  show  degenerative  changes  in  severe  cases, 
probably  due  to  the  action  of  toxins.  Occasionally 
other  organs  may  secondarily  become  affected  (otitis, 
pneumonia). 

The  inflammation  of  the  intestines  may  reach  any  de- 
gree of  severity,  and  is  dependent  to  some  extent  at  least 
upon  the  causative  organism,  being,  as  a  rule,  most 
marked  in  cases  in  which  dysentery,  typhoid,  and  strep- 
tococcic organisms  are  excitants  of  the  pathological 
process. 

It  may  be  a  hypersemia  and  swelling  associated  with 
exudation  of  excessive  amount  of  mucus  and  occasion- 


INFECTION   AND    NUTRITION.  257 

ally  of  blood,  producing  a  picture  of  catarrhal  gastro- 
enteritis marked  by  mucus,  mucopurulent,  and  occasion- 
ally also  slightly  bloody  diarrheal  stools.  These  cases 
are  caused  by  a  variety  of  bacteria,  and  they  are  often 
secondary  to  infections  of  the  respiratory  tract,  the  same 
micro-organisms  being  causative  in  both  instances.  We 
have  frequently  seen  such  a  clinical  picture  associated 
with  severe  vomiting,  and  a  secondary  acidosis  following 
in  the  course  of  a  streptococcus  sore  throat. 

Intense  swelling  of  Peyer's  patches  in  the  small  intes- 
tine is  seen  in  typhoid  infection.  Sloughing  and  ulcer 
formation  is  far  less  frequent  than  in  the  adults. 

In  paratyphoid  infections,  while  infiltration  of  Peyer's 
patches  and  solitary  follicles  are  usually  present,  deep 
ulceration  is  lacking,  as  a  rule. 

In  infection  with  dysentery  bacilli,  the  large  intestine  is 
especially  affected,  being  the  seat  of  sero-hemorrhagic 
and  hemorrhagico-purulent  inflammation,  with  marked 
tendency  to  formation  of  ulcers  throughout  a  large  part 
of  the  large  intestine,  and  less  frequently  the  lower  ileum. 

Again,  we  fnay  see  marked  intestinal  pathology,  as 
evidenced  by  deep-seated  ulcerations  and  infiltrations  of 
mucosa  and  secondary  inflammation  of  the  submucous 
and  muscular  layer  of  the  intestinal  wall,  which  condition 
is  usually  spoken  of  as  ulcerative  follicular  colitis,  and 
this  may  be  complicated  by  formation  of  a  pseudomem- 
brane  in  various,  areas  throughout  the  large  intestine, 
which  condition  has  been  described  as  a  membranous 
colitis.  In  many  of  these  cases  it  is  difficult  to  determine 
the  exact  bacteriological  factor,  because  of  the  presence 
of  secondary  organisms.  Most  of  these  cases  are  either 
subacute  or  seen  as  secondary  involvement  in  infants  who 
have  suffered  from  repeated  nutritional  disturbances. 

17 


258  INFANT   FEEDING. 

On  the  whole,  in  those  cases  of  inflammation  of  the 
intestinal  tract  due  to  bacterial  infection  and  presenting 
serious  pathological  changes,  the  most  marked  changes 
are  found  in  the  lower  three  feet  of  the  small  intestine 
and  in  the  large  intestine.  While  there  is  very  frequently 
a  disparity  between  the  severity  of  the  clinical  symp- 
toms and  the  pathological  changes  seen  post-mortem  in 
that  not  infrequently  severe  symptoms  are  associated 
with  little  pathology,  on  the  other  hand  marked  patho- 
logical changes  are  almost  invariably  associated  with  a 
severe  clinical  picture. 

Symptoms.  The  symptoms  vary  with  the  individ- 
ual excitant  of  the  disease,  and  thus  also  to  a  certain  ex- 
tent with  the  pathology,  but,  in  general,  the  symptoms 
are  so  variable  and  with  very  few  exceptions  so  little 
characteristic  for  the  particular  excitant  that  the  etio- 
logical and  pathological  grouping  of  clinical  pictures  is 
impractical.  It  seems  much  better  to  differentiate  the 
various  forms  from  the  clinical  point  of  view. 

Diarrhea  with  slimy  or  purulent  evacuations,  often 
with  blood,  accompanied  by  abdominal  pain,  tenesmus 
and  fever,  are  the  most  characteristic  and  the  most  con- 
stant symptoms  of  enteral  infections. 

The  onset  and  progress  of  enteral  infections,  as  a  rule, 
are  sudden  and  rapid,  and  in  this  way  they  markedly  dif- 
fer from  alimentary  nutritional  disturbances  in  which 
prodromes  consisting  of  milder  symptoms  are  often  pres- 
ent, and  the  progress  is  gradual.  In  enteral  infections  the 
stormy  course  may  result  in  rapid  production  of  a  very 
severe  picture  of  general  prostration,  and  even  an  early 
fatal  outcome. 

Diarrhea  is  so  constant  that  these  cases  have  been 
designated  as  ''infectious  diarrhea,"  and  yet  it  should  be 


INFECTION   AND   NUTRITION.  259 

remembered  that  typhoid  and  paratyphoid  infections  in 
young  individuals  may  be  associated  with  any  degree  of 
constipation  early  in  the  disease.  The  stools  are,  as  a 
rule,  frequent,  often  one  every  hour,  and  there  are  also 
cases  in  which  the  bowels  seem  to  move  almost  contin- 
uously. The  number  of  stools  varies  also,  according  to 
the  seat  of  the  most  severe  inflammation,  and  they  are 
more  numerous  when  the  large  intestine  is  chiefly 
affected. 

Loss  of  weight,  often  sudden  and  marked,  is  always 
present,  and  is  due  to  many  evacuations,  and  also  to  ac- 
companying nutritional  disturbance. 

Stools.  The  macroscopical  appearance  of  individual 
stools  varies  not  only  with  the  etiological  factor,  but  is 
also  dependent  to  a  great  extent  upon  the  reaction  to 
food,  and  upon  the  intestinal  pathology,  and  is  therefore 
of  little  value  in  the  etiological  diagnosis  of  enteral  in- 
fections. The  size  of  the  stools  is  indirectly  propor- 
tional to  their  number.  In  the  beginning  they  appear  to 
be  of  normal  composition,  but  sooner  or  later  they  are 
composed  chiefly  of  mucus  and  blood,  and  occasionally 
pus  may  be  seen,  even  by  the  unaided  eye.  Portions  of 
the  intestinal  mucous  membrane  are  seen  in  severe  cases 
at  the  time  of  sloughing  and  ulceration.  The  odor  of 
the  stool  varies  with  its  composition,  and  thus  with  the 
progress  of  the  disease.  In  the  beginning  the  odor  is  that 
of  the  normal  stool ;  later  stools,  composed  of  mucus  and 
blood,  are  almost  odorless ;  and  those  containing  large 
quantities  of  sloughs  have  often  a  putrefactiv-e  odor. 
The  reaction  of  the  stools  varies  also  with  their  composi- 
tion, being  mostly  alkaline.  In  exceptional  cases  the 
stools  may  not  be  considerably  increased  in  number,  and 
may  contain  neither  mucus,  nor  blood,  nor  pus. 


260  INFANT   FEEDING. 

Abdominal  pain  and  tenesmus^  due  to  irritation  by  the 
bacteria  and  their  products,  and  also  due  to  the  abnormal 
intestinal  contents,  and  to  increased  peristalsis,  and  some- 
times to  distention,  appear  very  early  in  the  disease,  often 
being  the  first  symptoms.  Although  being  severe  usu- 
ally, they  vary  from  a  slight  discomfort  to  excruciating 
pain,  which  keeps  the  child  constantly  awake,  and,  caus- 
ing exhaustion,  adds  to  the  severity  of  the  case.  Ab- 
dominal distention  is  intermittent,  the  abdomen  being 
usually  sunken.  Abdominal  tenderness  is  not  frequent. 
Anorexia  is  almost  always  present,  while  vomiting  is 
more  commonly  seen  early. 

Fever  is  always  present  in  enteral  infections,  and  varies 
with  the  severity  of  the  infection  and  the  pathology. 
More  often  it  is  not  extreme  after  the  first  exacerbations. 
It  persists  throughout  the  disease. 

Leucocytosis  and  oliguria  are  usually  present. 

Enteral  infections  are  always  associated  with  nutri- 
tional disturhances,  since  the  infection  affects  an  organ 
chiefly  concerned  in  nutritional  processes.  And  nutri- 
tional disturbances,  again,  produce  symptoms  of  their 
own. 

The  course  of  enteral  infections  varies  considerably, 
being  dependent  chiefly  upon  the  nature  of  the  organism 
and  the  stage  of  nutritional  disturbance  that  develops, 
and  also  on  the  nature  of  complications.  Some  cases 
may  be  so  mild  as  to  resemble  subacute  dyspepsia,  and 
only  inability  to  influence  the  fever  by  the  diet  may  point 
to  their  true  nature.  On  the  other  hand,  however,  severe 
toxic  conditions  occur,  being  due  either  to  sepsis  or  to  a 
nutritional  disturbance  which  develops  secondarily  to  in- 
fection. The  duration  of  the  disease  varies  from  a  few 
days  to  several  weeks. 


INFECTION   AND   NUTRITION.  261 

Complications.  The  great  danger  of  the  infections 
of  the  gastro-intestinal  tract  Hes  in  their  tendency  to 
comphcations,  at  the  head  of  which  stand  nephritis  and 
pneumonia.  Other  comphcations  are  cysto-pyeHtis  and 
various  pyodermatoses,  and  other  pus  infections  and  gen- 
eral pyaemia  or  septicaemia,  which  start  either  from  the 
skin  or  from  the  diseased  intestines. 

More  important  than  this  is  the  association  of  infec- 
tious diseases  of  the  intestines  with  secondary  nutritional 
disturbances.  It  is  easy  to  understand  that  in  severely 
diseased  intestines  the  normal  digestion  of  food  is  made 
especially  difficult,  and  thus  acid  decomposition  easily 
occurs,  which  in  turn  leads  to  dyspepsia,  and  in  the  wake 
of  these  even  the  alimentary  decomposition  and  alimen- 
tary intoxication  may  be  implanted  upon  the  original  dis- 
ease. The  inanition  caused  by  the  flour  injuries 
(Mehlnahrschaden)  may  in  some  cases  reach  disastrous 
gravity.  There  can  be  no  doubt  that  the  majority  of  the 
cases  resulting  in  decomposition  are  not  due  to  the  in- 
fection alone,  but  also  to  the  inanition  and  other  forms 
of  secondary  nutritional  disturbances,  and  it  is  probable 
that  even  a  part  of  the  severe  ulcerative  forms  and  vari- 
ous complications  develop  on  the  same  foundation.  The 
underfeeding  alone  gradually  decreases  the  general  power 
of  resistance  of  the  body;  it  weakens  also  the  antibac- 
terial functions,  and  thus  the  local  or  general  infection 
may  spread  unimpeded. 

Diagnosis.  In  making  a  diagnosis  it  is  necessary  to 
differentiate  the  enteral  infections  not  only  from  (1) 
alimentary  nutritional  disturbances,  but  also  from  (2) 
nutritional  disturbances  caused  by  parenteral  infections. 
(3)  Diagnosis  of  the  causative  organism  or  group  of 
organisms  is  also  of  great  importance  for  the  treatment. 


262  INFANT   FEEDING. 

(4)  Enteral  infections  are  always  complicated  by  nutri- 
tional disturbances,  and  it  is  of  great  importance  to  recog- 
nize the  degree  (dyspepsia,  'intoxication,  decomposition) 
to  which  the  infant  is  affected. 

In  practice  it  is  often  difficult  to  differentiate  clinically 
the  gastro-intestinal  infection  from  other  forms  of  ali- 
mentary disturbances,  because  neither  bloody  and  puru- 
lent stools  nor  the  finding  of  pathogenic  bacteria  in  the 
stools  in  itself  is  sufficient  for  the  diagnosis  of  enteral 
infection,  except  possibly  in  the  presence  of  typhoid, 
paratyphoid,  and  d3^sentery  bacilli. 

An  easily  applicable  method  of  differentiation  is  the 
test  for  the  reaction  to  starvation  and  feeding.  Fever 
continuing  after  withdrawal  of  food  speaks  for  infec- 
tious etiology.  Inability  to  influence  the  symptoms  by 
diet  is  to  be  interpreted  in  the  same  sense. 

History  is  of  considerable  importance  in  making  a  dif- 
ferential diagnosis.  The  acute  infectious  diarrhea  starts 
usually  suddenly  in  a  previously  well  baby,  and  pros- 
trates it  at  once,  while  the  alimentary  nutritional  disturb- 
ance comes  on  gradually.  In  the  latter  we  get  a  history 
of  improper  feeding,  of  previous  nutritional  disturbance, 
of  parenteral  infection.    It  is  more  gradually  progressive. 

The  differentiation  between  the  enteral  and  the  paren- 
teral infections  is  somewhat  more  difficult,  and  is  to  be 
made  chiefly  by  exclusion  of  the  parenteral  infection  by 
careful  physical  examination  of  the  patient.  The  bloody, 
purulent  stools  are  usually  absent  in  the  cases  secondary 
to  parenteral  infection. 

The  diagnosis  of  the  causative  organism  is  to  be  made 
by  proper  bacteriological  examination  and  culture  of  the 
stools,  and  by  agglutination  reaction.  Kendall  states  that 
frequently  it  is  very  difficult  to  determine  the  organism 


INFECTION   AND   NUTRITION.  263 

causing  the  disease,  and  therefore  he  has  attempted  to 
classify  the  causative  organisms  into  two  groups  with  a 
special  reference  to  treatment.*  He  divides  them  into 
two  large  groups:  (1)  the  various  forms  of  dysentery- 
bacillus  and  all  other  organisms  except  the  gas  bacillus ; 
(2)  the  gas  bacillus  and  the  allied  organisms. 

While  this  classification  of  organisms  for  treatment 
theoretically  offered  great  advantages,  in  our  own  clinical 
work  we  have  not  experienced  the  encouraging  clinical 
results  which  might  be  expected,  and  have  instituted  a 
general  course  of  treatment  based  more  directly  on  the 
severity  of  the  infection  and  the  symptoms  as  presented 
by  the  cases  at  hand. 

Stool  cultures  should  be  made  according  to  the  method 
of  Kendall  for  gas  bacillus.  This  method  is  so  simple 
that  it  may  be  performed  even  outside  of  a  well  equipped 
laboratory.  Small  portion  of  the  stool  is  added  to  a  test- 
tube  of  milk.  The  test-tube  is  then  heated  on  the  water- 
bath,  and  left  in  the  boiling  water  for  three  minutes.  By 
this  procedure  all  the  bacteria  in  the  stool  that  are  not 
in  stage  of  spores,  are  killed,  and  the  bacteria  develop  un- 
restrained from  the  spores  subsequently.  Gas  bacillus, 
being  sporogenous,  survives  the  boiling.  The  test-tube 
is  finally  incubated  at  a  body  temperature  for  about 
twenty-four  hours.  In  the  presence  of  the  gas  bacillus  a 
large  part  of  the  casein  is  dissolved,  but  the  remaining 
casein  is  filled  with  holes,  as  if  shot  to  pieces,  and  some- 
what pinkish  in  color.  The  odor  reminds  one  of  rancid 
butter,  and  is  due  to  forrnation  of  butyric  acid.  The  true 
reaction  may  be  easily  differentiated  from  the  pseudo- 
reactions,  in  which  some  liquefaction  of  casein  also  oc- 


*  Kendall  and  Smith :     Bost.  Med.  and  Surg.  Jour.,  1910,  clxiii, 

578. 


264  INFANT   FEEDING. 

curs,  but  in  which  the  shotted  appearance  of  the  residual 
casein  and  the  odor  of  butyric  acid  are  absent. 

Differential  studies  for  typhoid,  paratyphoid,  and  dys- 
entery bacilli  on  endomedium  and  Russell's  double  sugar 
medium,  and  by  further  fermentation  tests,  are  indicated 
in  the  presence  of  epidemic  or  severe  endemic  cases. 

While  agglutination  reactions  are  uncertain  in  very 
young  infants,  because  of  the  slight  tendency  to  the  for- 
mation of  agglutinins,  in  older  infants  and  children  it  is 
of  very  considerable  value,  as  demonstrated  by  the  study 
of  agglutinins  by  the  author  at  Cook  County  and  Sarah 
Morris  Hospitals  during  the  year  1914.  In  a  series  of 
30  cases  studied  in  which  agglutinations  were  made  for 
typhoid,  paratyphoid  (alpha,  beta,  and  Morgan),  dysen- 
tery (Shiga  and  Flexner),  and  colon  bacilli,  the  follow- 
ing organisms  were  demonstrated:  typhoid,  2;  paraty- 
phoid (Morgan),  1;  dysenter}^,  2.  All  of  these  cases 
yielded  the  respective  organisms  in  large  numbers  from 
their  stool  cultures.  This  method  of  examination  is 
easily  carried  out  in  a  well  regulated  laboratory,  and  is 
worthy  of  further  consideration  in  the  presence  of  an 
epidemic  of  enteritis  or  isolated  cases  of  severe  enteral 
infection. 

The  stage  of  the  nutritional  disturbance  is  best  diag- 
nosed by  the  reaction  of  the  temperature  and  toxic  symp- 
toms to  complete  withdrawal  of  food,  and  presence  or 
absence  of  paradoxical  reaction.  (See  also  Dyspepsia,  p. 
201 ;  Decomposition,  p.  214;  Intoxication,  p.  232.)  Star- 
vation in  the  presence  of  infection  must  always  be  recog- 
nized as  a  dangerous  procedure. 

Prognosis.  The  prognosis  of  enteritis  is,  in  general 
favorable.  Death  is  almost  always  due  to  complications 
with  septic  affections  or  nutritional  disturbances. 


'  INFECTION   AND   NUTRITION.  265 

In  infants  and  younger  children  the  prognosis  depends 
essentially  upon  the  ability  of  the  physician  to  apply  the 
proper  dietetic  methods  suitable  for  the  particular  case. 
If  he  succeeds — and  this  is  at  present  possible  in  very 
many  cases — to  avoid  graver  secondary  nutritional  dis- 
turbances, then  he  will  be  able  to  save  a  surprisingly 
large  percentage  of  cases;  if  he  is  unsuccessful  in  this 
direction,  then  his  results  will  be  unsatisfactory. 

Treatment.  Prophylaxis.  In  etiology  of  enteral  in- 
fections several  facts  based  on  bacteriological  studies  and 
clinical  observations  stand  out  so  prominently  that  the 
methods  of  prophylaxis  must  be  based  upon  them  in 
order  to  be  successful. 

1.  In  the  great  majority  of  cases  the  infection  is  intro- 
duced with  the  food.  Whenever  intestinal  infection  oc- 
curs in  a  breast-fed  infant  in  a  private  home,  the  first 
thought  should  be  that  the  infant  was  probably  getting 
other  food  besides  mother's  milk,  and  only  after  exclu- 
sion of  this  probability  the  causes  should  be  looked  for 
in  the  environment  of  the  infant,  especially  the  cleanli- 
ness of  the  mother  and  the  general  hygiene  of  the  home. 
In  artificially  fed  infants  the  prophylaxis  of  enteral  in- 
fections consists  of  obtaining  pure  and  wholesome  milk, 
keeping  it  clean,  boiling  when  in  doubt,  and  careful  prep- 
aration of  proper  mixtures. 

2.  In  many  cases  the  infection  occurs  by  contact,  espe- 
cially in  institutions.  Isolation  of  severe  cases  of  intes- 
tinal infection  is  therefore  essential,  and  isolation  of  all 
suspicious  cases  advisable,  especially  in  institutions. 

3.  The  environment  of  the  infant,  and  especially  lack 
of  proper  cleanliness  generally,  and  in  preparation  of 
foods  especially,  are  very  frequently  predisposing  and 
9.ccessory  factors,    The  methods  instituted  to  counteract 


266  INFANT    FEEDING. 

these  influences  must,  of  course,  be  adapted  to  the  in- 
dividual case. 

4.  ^Parenteral  infections  are  often  followed  by  enteral 
infections.  Proper  treatment  of  parenteral  infection, 
special  attention  to  the  diet  and  general  hygiene,  are  the 
keynote  of  prophylaxis  in  these  cases,  the  possibility  of 
secondary  enteral  infection  being  constantly  kept  in  mind. 

5.  Alimentary  nutritional  disturbances  increase  suscep- 
tibility to  any  form  of  infection,  and  especially  to  enteral 
infection,  and  the  prophylaxis  of  secondar}^  enteral  in- 
fections coincides  practically  with  the  prevention  and 
proper  treatment  of  these  nutritional  disturbances.  (See 
also  "Susceptibility  Influenced  by  Nutrition,"  p.  245.) 

Initial.  The  object  of  the  initial  treatment  is  to  de- 
crease as  much  as  possible  the  number  of  bacteria  present 
in  the  intestine,  and  the  removal  of  irritating  intestinal 
contents.  Intestinal  disinfection  by  drugs  is  impossible; 
and  the  cleansing  of  the  intestines  by  the  administration 
of  large  quantities  of  inert  fluids,  enemata,  and  possibly 
an  initial  laxative,  is  the  best  that  can  be  done  in  this 
direction. 

Castor  oil,  which  is  usualh^  taken  plain  without  any 
difficulty  by  infants,  in  doses  of  1  to  2  teaspoonfuls,  is 
the  best  laxative  for  these  cases,  since  it  causes  very 
little  intestinal  irritation.  Only  in  cases  where  it  is 
vomited,  we  should  resort  to  magma  magnesias  (^  to  4 
teaspoonfuls),  or  to  calomel,  0.06  gram  (1  gr.),  given 
in  doses  of  0.015  gram  (^  gr.)  every  half  an  hour  until 
four  doses  are  given.  Calomel  is  administered  with 
sodium  bicarbonate.  The  calomel  can  be  followed  to 
advantage  with  1  or  2  teaspoonfuls  of  magma  magnesise. 

An  enema  of  physiological  saline  (1  teaspoonful  of 
salt  to  1  pint  of  water)  is  useful. 


INFECTION   AND    NUTRITION.  267 

All  food  should  he  stopped  for  from  six  to  twelve 
hours.  It  is  not  desirable,  as  a  rule,  to  withhold  the  food 
longer  than  this  time. 

Water  should  be  given  freely  during  the  starvation 
period,  and  in  quantities  that  are  at  least  equal  to  the 
past  total  intake  of  fluids.  The  water  may  be  given 
either  warm  or  cool,  or  in  the  form  of  weak  tea.  Sac- 
charin may  be  used  to  sweeten  it,  using  0.01  gram 
(%  §!"•)  of  saccharin  to  8  ounces  of  water,  if  desired. 
In  presence  of  marked  anorexia  or  refusal  of  fluid  on  the 
part  of  the  infant,  the  water  or  tea  must  be  ad- 
ministered by  catheter.  In  persistent  vomiting  frequent 
resort  to  gastric  lavage  with  1  per  cent,  sodium  bicar- 
bonate solution  will  relieve  vomiting,  and  be  followed  by 
retention  of  fluids  given  by  mouth.  When  the  latter  does 
not  relieve  the  vomiting,  physiological  saline  solution  or 
Ringer's  solution  must  be  given  either  by  rectum  or 
subcutaneously. 

Medicinal  Treatment.  Abdominal  pain  and  tenesmus 
are  often  so  severe  that  they  require  a  special  treatment. 
Moist  heat  in  the  form  of  compresses,  hot  water  bottles 
or  electric  pads  should  be  given  preference,  and  only  in 
cases  in  which  they  do  not  afford  relief  recourse  should 
be  had  to  opium  or  morphine.  Tincture  of  opium  in 
doses  of  3  to  5  drops  may  be  given  in  10  per  cent,  starch 
solution  by  the  rectum,  or  0.01  to  0.03  gram  (%  to  ^  gr.) 
of  pulvis  ipecacuanhse  et  opii  (Dover's  powder)  (beware 
of  vomiting),  or  5  to  20  drops  of  tinctura  opii  camphorata 
(paregoric)  by  mouth.  In  some  cases  1  or  2  doses  of 
morphine  may  be  preferable,  since  it  decreases  the  peris- 
.  talsis  less  markedly  than  opium ;  the  dangers  of  its  admin- 
istration to  infants  must  be  remembered,  and  the  dosage 
must  be  minimal  (0.0003  to  0.001  gram — %oo  to  %o  g^O- 


268  INFANT   FEEDING. 

Stimulants  are  indicated  in  some  cases  of  extreme  ex- 
haustion, and  in  cases  of  sudden  collapse.  In  the  ab- 
sence of  hyperexcitability  of  the  nervous  system,  strych- 
nin is  the  most  generally  useful  stimulant.  It  is  given 
in  doses  of  0.00005  to  0.0003  gram  (i^ooo  to  1/200  gr.)- 
Caffein  in  the  form  of  caffein  sodium  benzoate,  or 
citrated  caffein,  are  of  value,  and  are  given  in  doses  of 
0.01  to  0.03  gram  (%  to  >^  gr.).  Camphor  0.05  to  0.10 
gram  (1  to  2  gr.)  dissolved  in  sterile  oil  may  be  injected 
subcutaneously  in  emergency. 

Special  symptoms  and  conditions  arising  during  the 
course  of  the  disease,  as  are  high  fever,  excessive  vomit- 
ing, symptoms  of  ner^'ous  excitation,  or  extreme  depres- 
sion, are  to  be  treated  as  detailed  under  Intoxication 
(p.  232). 

Injections  of  silver  ■nitrate  are  of  value  in  some  cases 
where  blood  and  pus  persist  in  the  stool  even  after  the 
subsidence  of  acute  symptoms,  and  especially  in  dysen- 
tery. Before  an  injection  is  given,  the  colon  should  be 
irrigated  first  with  sterile  water  (not  saline).  One 
per  cent,  silver  nitrate  solution  is  then  injected  in  a  suit- 
able quantity.  If  it  causes  any  pain  or  irritation,  it 
should  be  washed  out  with  saline  solution.  It  should  not 
be  repeated  more  often  than  once  a  day,  and  if  three 
injections  do  not  result  in  marked  improvement  it  is 
better  to  discontinue  them. 

Dietetic  Treatment.  Human  Milk.  The  ideal  treat- 
ment for  all  cases  of  intestinal  infections  would  most 
naturally  be  best  accomplished  by  feeding  with  human 
milk,  and  whenever  obtainable,  more  especially  in 
the  severe  types,  it  is  by  all  means  the  diet  of  choice. 
Feeding  with  human  milk,  especially  in  young  infants, 
produces   ver\'    good    results,   because   it   retards   the 


INFECTION   AN.D   NUTRITION.  269 

complicating  nutritional  disturbance,  and  thus  favors 
healing. 

Artificial  Feeding.  From  the  great  number  of  food 
mixtures  that  have  been  advised  for  enteral  infections, 
we  may  judge  as  to  the  lack  of  any  specific  action.  It  is 
probable  that  success  may  be  obtained  with  any  feeding 
which  prevents  the  aggravation  of  nutritional  disturb- 
ance, and  favorably  influences  the  nutritional  disturb- 
ance which  may  exist.  Feeding  with  albumin  milk,  skim 
and  buttermilk,  and  cereal  mixtures  and  whey-cereal 
mixture  (Frank)  offer  the  least  risk. 

Prolonged  starvation  by  insufficient  diet  or  by  refusal 
on  the  part  of  the  infant  to  take  the  prescribed  diet  is 
always  disastrous,  and  must  be  avoided.  After  six,  or 
at  the  most  twelve,  hours  on  the  tea  diet  the  infant  is 
placed  on  cereal  water  (barley,  rice,  or  flour  ball),  using 
1  tablespoonful  of  the  flour  to  a  pint  of  water  in  young 
infants,  and  2  tablespoonfuls  to  the  pint  of  water  in 
infants  over  1  year.  After  twenty-four  to  forty-eight 
hours  on  the  above  diet  an  ounce  of  clear  chicken  or 
lamb  broth  can  be  added  to  the  above  cereal  w^aters, 
seasoning  with  a  small  amount  of  salt.  If  the  child  will 
take  the  food,  it  may  be  given  in  the  same  quantities  to 
which  the  child  has  been  accustomed,  or  smaller  quanti- 
ties at  more  frequent  intervals. 

By  far  the  best  results  obtained  in  our  private  and  hos- 
pital work  have  been  by  instituting  feeding  with  albumin 
milk  of  Finkelstein  after  the  first  twenty-four  hours  on 
an  inert  diet.  The  value  of  the  albumin  milk  may  be 
explained  by  the  fact  that  it  is  easily  digestible,  contain- 
ing moderate  quantities  of  fat  and  sugar  and  finely 
divided  casein,  which  is  easily  digested  in  this  form.  The 
rules  to  be  followed  in  the  feeding  with  albumin  milk 
are  described  under  Decomposition.    This  diet  is  also  to 


270  INFANT   FEEDING. 

be  recommended  in  home  practice,  wherever  it  is  pos- 
sible to  obtain  it,  either  from  a  neighboring  hospital  or 
by  instruction  of  the  nurse  or  of  the  mother.  Feeding 
with  albumin  milk  should  be  begun  after  twenty-four 
hours  on  the  tea  and  cereal  water  diet.  Sufficient  quan- 
tity of  inert  fluid,  either  in  the  form  of  water,  tea,  or 
cereal  water  should  be  given  with  or  between  the  small 
feedings  of  albumin  milk.  One  of  the  gravest  dangers 
in  the  severe  infections  is  that  the  infants  are  likely  to 
take  too.  little  rather  than  too  large  quantities,  and  are 
especially  prone  to  vomit  when  the  food  is  forced  upon 
them. 

Boiled  skim  buttermilk  or  skim  milk  with  starch  or 
flour  ball  added  (1  tablespoonful  to  the  pint)  may  be 
used  as  substitute,  if  albumin  milk  cannot  be  obtained. 
They  are,  however,  not  so  efficacious.  They  should  be 
fed  in  small  quantities,  as  recommended  for  albumin 
milk. 

Chymogen  milk  (either  made  from  the  whole  milk,  or 
in  severe  types  from  skim  milk),  either  diluted  or  in 
small  quantities,  if  given  full  strength,  is  frequently  re- 
tained when  the  stomach  is  very  irritable,  and  where  the 
child  objects  to  the  less  palatable  albumin  milk  and  but- 
termilk mixtures. 

The  whey-cereal  mixture  therapy  of  Frank  deserves 
a  special  mention.     It  is  administered  as  follows : 

1st  day:  Initial  starvation  period  on  tea  for  not  longer 
than  twelve  hours. 

2d  day :  Feed  five  times  50  grams  whey  and  50  grams 
cereal  gruel  prepared  from  crushed  grain. 

3d  day :  Increase  to  60  grams  whey  and  60  grams 
cereal  gruel. 

4th  day:   75  grams  whey  and  75  grams  gruel. 


INFECTION   AND    NUTRITION.  271 

5th  to  8th  day:  Not  later  than  on  the  fifth  to  eighth 
day  of  treatment  replace  a  tablespoonful  of  whey  by 
tablespoonful  of  milk.  Increases  of  milk  to  be  guided  by 
the  infant's  progress  and  needs. 

9th  to  11th  day:  Increase  the  addition  of  milk 
gradually. 

12th  to  14th  day :  Even  in  the  grave  case  400  grams  of 
milk  and  400  grams  of  cereal  gruels  and  200  grams  of 
meat  broth  must  be  given,  and  not  later  than  in  this  time 
the  broth  is  to  be  prepared  with  strained  rice  or  farina. 
In  infants  over  1  year,  beginning  with  the  tenth  day, 
finely  scraped  beef  may  be  added. 

A  careful  record  should  be  kept  of  the  exact  amount 
of  milk  and  other  fluids  taken  in  each  twenty-four  hours, 
and,  where  possible,  the  child  should  be  weighed  daily  to 
ascertain  the  loss  in  weight. 

The  dietetic  therapy  has  never  such  a  prompt  result  as 
in  alimentary  nutritional  disturbances.  Even  in  favor- 
able cases  the  disease  (purulent  and  bloody  stools,  fever) 
continues  for  one  week;  in  unfavorable  cases,  several 
weeks.  Strict  adherence  to  the  food  regime  once  insti- 
tuted is  desirable.  In  these  cases  no  greater  mistake 
could  be  made  tham  to  change  diet  with  introduction  of 
repeated  hunger  days,  or  to  remain  on  small  quantities  of 
food.  Thus,  an  infant  suffering  from  infection  succumbs 
often  not  to  the  infection,  not  to  the  nutritional  disturb- 
ance, but  to  inanition. 

Diet  in  Convalescence.  The  problem  of  nutrition 
offers  great  difficulties,  even  after  the- subsidence  of  the 
fever,  and  following  the  improvement  in  the  number  and 
character  of  the  stools,  as  it  is  frequently  necessary  to 
keep  the  infant  on  a  restricted  diet  for  from  one  to  three 
weeks.    Only  rarely  it  is  possible  to  feed  sufficient  caloric 


272  INFANT   FEEDING. 

units  for  the  maintenance  of  weight  during  the  first  and 
the  second  weeks  of  the  illness.  Where  possible,  the 
albumin  milk,  buttermilk,  skim  milk,  and  chymogen  milk 
and  cereal  gruels  should  be  gradually  increased,  and 
these  increases  in  quantity  should  be  maintained  even  in 
the  presence  of  moderately  bad  stools  if  vomiting  is  ab- 
sent, unless  one  becomes  convinced  that  one  or  the  other 
of  the  food  elements  is  absolutely  detrimental  to  the 
infant's  welfare. 

It  is  our  desire  to  impress  that  possibly  the  gravest  dan- 
ger to  the  infant  during  the  period  of  convalescence  is 
that  of  underfeeding.  Upon  the  return  to  milk  mixture 
small  quantities  of  boiled  milk,  low  in  fat  (albumin  milk, 
buttermilk,  skim  milk)  should  at  first  be  used.  This  may 
be  accomplished  by  adding  it  to  the  cereal  gruels.  Dur- 
ing this  stage  beef  juice  broths,  ^gg  albumin,  coddled 
tgg  (prepared  as  for  typhoid  fever  patients),  zwieback 
crumbs,  pap,  custards,  and  junket  may  be  added.  Under 
conditions  where  ideal  milk  and  milk  preparations  can- 
not be  obtained,  we  have  found  that  not  infrequently  the 
better  brand  of  evaporated  milk,  as  obtained  on  the  open 
market,  are  useful,  when  properly  diluted.  The  use  of 
condensed  milk  should  be  avoided. 

The  obstinate  constipation  which  is  sometimes  seen 
during  convalescence  should  be  treated  with  the  utmost 
conservatism,  along  the  lines  as  laid  down  for  constipa- 
tion. The  infant  should  have  at  least  one  evacuation  of 
the  bowels  daily.  A  saline  enema  is  usually  sufficient  to 
produce  this  result. 


Appendix. 


PROPRIETARY    BABY    FOODS. 

It  should  be  borne  in  mind  that  the  average  daily  cost 
of  many  of  the  proprietary  baby  foods  is  in  excess  of 
twenty-five  cents. 

For  practical  purposes  the  baby  foods  may  be  classed 
as  follows : 
Group  I,  Prepared  from  cow's  milk. 

1.  Condensed  milk  without  added  sugar. 

2.  Condensed     milk     with     added     sugar     (Borden's 

Eagle  Brand)  (F.,  8.85;  P.,  7.34;  milk-sugar, 
11.61;  cane-sugar,  42.9;  ash,  1.77;  water,  27.53). 

3.  Evaporated  milk   (St.  Charles)    (P.,  9.0;  P.,  7.82; 

milk-sugar,  11.19;  ash,  1.71;  water,  69.91). 

4.  Peerless  Brand  unsweetened  evaporated  milk   (F., 

9.27;  P.,  7.28;  milk-sugar,  9.99;  ash,  1.51;  water, 
71.82). 

5.  Carnation  Brand. 

6.  Lacta  Praeparata  (powder). 

7.  Mammala    (powder)    (F.,    12.12;   P.,  24.35;  milk- 

sugar,  55.34;  ash,  5;  moisture,  3.19). 

8.  Honor  Brand  powdered  milk   (F.,   12.0;  P.,  34.0; 

milk-sugar,  44.0;  ash,  7.0;  moisture,  3.0). 

9.  Merrill-Soule   powdered   modified   milk    (F.,    18.0; 

casein,  8.6;  albumin,  7.5;  milk-sugar,  57.8;  ash, 
7.Z\  moisture,  1.2).  Calories,  133  per  ounce.  To 
be  used  1  part  food  to  from  4  to  10  parts  of 
water. 

18  (273) 


274  INFANT   FEEDING. 

Group  II.     Foods  prepared  from  dried  cow's  milk  and 
modified  cereals.     To  be  diluted  with  water  only. 

(A)  Containing  much  unchanged  starch. 

1.  Nestle's   Food    (milk-sugar,    7.4;   maltose,    15.6; 

cane-sugar,  24.77;  starch,  17.31;  protein,  10.92; 
dextrin,  13.51;  fat,  5.63;  ash,  1.49;  water, 
3.37). 

2.  Anglo-Swiss. 

(B)  Starch   largely   converted   into    soluble   carbohy- 

drates, such  as  maltose  and  dextrin. 

1.  HorHck's  Malted  Milk   (F.,  8.5;  P.,   16.3;  mal- 

tose and  dextrin,  18.80;  lactose,  49.15;  ash, 
3.8;  water,  3.0). 

2.  Allenberry's  I  and  II.     (No.  I,  F.,  17.2;  P.,  10.6; 

maltose,  14.0;  dextrin,  10.0;  lactose,  42.0;  ash, 
3.0.)  (No.  II,  F.,  15.88;  P.,  9.90;  maltose, 
20.0;  lactose,  36.0;  dextrin,  13.0;  salts,  3.71.) 

Group  III.  Foods  prepared  from  modified  cereals  to  be 
used  wnth  fresh  cow's  milk. 

(A)  Starch  unchanged. 

1.  Flours    of    barley,   wheat,    rice,    corn,    oats,    soy 

beans,  etc.  (Barley  flour,  1  level  tablespoonful 
(98  grains)  to  12  ounces  water  equals  1.27 
starch  or  1.8  calories  per  ounce.) 

2.  Arrowroot. 

(B)  Starch  partially  dextrinized. 

1.  Robinson's  patent  barley  flour. 

2.  Imperial  Granum  (F.,  1.4;  P.  14.0;  carbohydrates 

(sol.),  1.8;  carbohydrates  (insol.),  73.5;  ash, 
0.39;  water,  9.0). 


APPENDIX.  275 

3.  Eskay's  Food    (contains  a  small  amount  of  egg 

albumin)  (F.,  1.0;  P.,  6.7;  carbohydrates  (in- 
sol.),  21.21;  carbohydrates  (sol.),  67.81; 
ash,  1.3). 

4.  Denno's   Baby   Food    (F.,    1.79;   P.,    11.0;   cane- 

sugar,  15.2;  starch,  64.6;  ash,  1.12;  water, 
6.2). 

5.  Allenberry's    No.    Ill    (malted)     (F.,    1.05;    P., 

10.23;    carbohydrates    (sol.),    25.00;    maltose, 
16.5;     dextrin,     8.5;     carbohydrates     (insol.), 
60.01;  ash,  0.60). 
(C)    Starch     completely     changed     to     dextrin     and 
maltose : 

1.  Borcherdt's    Dri-Malt    Soup    Extract    (maltose, 

71.10;  dextrin,  13.50;  protein,  8.66;  ash,  2.94; 
moisture,  3.80).  Calories  per  ounce  by  weight 
equals  110.  It  is  a  laxative,  and  is  easily  di- 
gested because  of  the  high  maltose  and  potas- 
sium carbonate  (1.1  per  cent.)  contents. 

2.  Borcherdt's   Malt   Soup   Extract    (protein,   6.40; 

maltose,  57.57*  dextrin,  11.70;  ash,  2.54;  mois- 
ture, 21.79).  It  contains  1.1  per  cent,  potas- 
sium carbonate. 

3.  Borcherdt's  Dri-Malt  Soup  Extract  with  Wheat 

Flour.  Semi-liquid  malt  soup  extract,  to 
which  gelatinized  wheat  flour  has  been  added, 
and  the  whole  dried.  One  ounce  equals  110 
calories. 

4.  Borcherdt's  Malt  Sugar   (dry)    (maltose,  87  per 

cent.;  dextrin,  5  per  cent.).  The  following 
table  will  give  a  comparative  idea  of  the  rela- 
tive value  by  weight  and  measure  of  Bor- 
cherdt's liquid  and  dri-malt  soup  extracts: 


276  INFANT   FEEDING. 

16  Fluid  oz.  equal  19.5  oz.  dry  malt  powder  by  measure. 
1  Fluid  oz.  equals  1.2  oz.  dry  malt  powder  by  measure. 
1  oz.  of  liquid  by  weight  equals  0.83  oz.  of  powder. 
1  Fluid  oz.  represents  90  calories. 
1  Ounce  of  powder  by  weight  represents  110  calories. 

5.  Horlick's  Malt  Food  (contains  no  milk)   (F.,  1.4; 

P.,  12.06;  maltose,  17.86;  salts,  2.6).  Calories, 
109.29. 

6.  Mellin's    Food    (F.,    0.16;    P.,    10.35;    maltose, 

58.88;  dextrin,  20.69;  carbohydrates  (sol.), 
79.57;  salts,  4.3;  water,  5.6).     Calories,  91.43. 

7.  Dextri-maltose    (Mead's    No.    1)     (maltose,    52; 

dextrin,  41;  water,  5;  sodium  chloride,  2).  No. 
2  (maltose,  53;  dextrin,  42;  water,  5).  No.  3 
(maltose,  52;  dextrin,  41;  water,  5;  potassium 
carbonate,  2). 

8.  Nahrzucker  (Sohxlet)    (R,  0.03;  P.,  0.13;  mal- 

tose, 41.0;  dextrin,  53.3;  ash,  1.7;  water,  2).   . 
Group  R^.  Foods  prepared  from  casein. 

1.  Larosan   (casein  plus  calcium). 

2.  Xutrol  (sodium  compound  of  casein). 

3.  Plasmon     (from    casein    by    action    of    CO2    and 

NaHCOs). 
Group  V.  Diastatic  ferments. 

1.  Diastoid   (Horlick's,  powder). 

2.  Diazyme  (Fairchild,  liquid),  a  good  product. 
Group  VL  Peptonizing  powders. 

1.  Peptogenic  milk  powder  (Fairchild's). 

2.  Pepsin. 

Group   VII.  Rennet  powders    (precipitating  curd  in  a 
finely  divided  form). 

1.  Chymogen  (rennin  and  milk-sugar). 

2.  Pegnin   (rennin). 


APPENDIX.  277 

It  will  be  noticed  that  there  are  two  great  classes  of 
proprietary  infant  foods : 

The  First.  (Groups  I,  II).  Those  containing  cow's 
milk. 

Sweetened  Condensed  Milks.  These  are  advertised  as 
complete  infant  foods.  All  of  them  are  quite  similar  in 
composition.  All  contain  large  amounts  of  cane-sugar. 
It  is  impossible  to  make,  by  simply  adding  water,  a 
properly  balanced  food  for  an  infant's  continuous  diet. 
A  dilution  to  give  a  rational  amount  of  proteins  and  fats 
has  a  large  excess  of  sugars,  and  one  to  contain  any 
amount  under  7  per  cent,  total  sugar  would  be  so  weak 
in  both  protein  and  fat  that  the  baby's  proper  growth 
would  be  very  seriously  interfered  with. 

Eagle  Brand  condensed  milk  contains:  fat,  8.85;  pro- 
teins, 7.34;  milk-sugar,  11.61;  cane-sugar,  42.90;  ash, 
1.77;  water,  27.5. 

TABLE. 

A  Well-known   Condensed   Milk,    Showing  the   Content 
of  Various  Dilutions.    Fats  and  Proteins  Deficient. 

Full  6  parts  12  parts  18  parts 

strength  water  water  water 

Per  cent.         Per  cent.         Per  cent.  Per  cent. 

Fat    6.94  .99  .53  .36 

Proteid    8.43  1.2  .65  .44 

Cane-sugar  ...  50.69  7.23  3.90  2.67 

Salts   1.39  .17  .10  .07 

Water 31.30  90.49  94.80  96.46 

The  Unszveetened  Evaporated  Milks.  They  were  made 
by  heating  the  milk  to  200°  F.,  and  then  transferring  it 
to  vacuum  pans,  where  it  is  maintained  at  a  temperature 
of  125°  F.,  until  sufficient  water  is  evaporated  to  bring 
the  product  to  the  required  condensation.  In  most 
products  this  milk  is  about  double  strength. 


278  INFANT   FEEDING. 

The  sugar  content  not  being  in  excess,  these  milks  can 
be  so  diluted  that  a  reasonable  amount  of  fat  and  protein 
can  be  obtained,  with,  however,  a  considerable  deficiency 
in  sugar;  this  relatively  low  amount  of  carbohydrate  can 
then  be  made  up  by  adding  sugar  (cane  or  maltose-dex- 
trin compounds),  much  the  same  as  is  done  with  cow's 
milk.  \Miere  it  is  impossible  to  obtain  clean,  fresh  milk, 
evaporated  milk  can  be  used  with  good  success  as  a  tem- 
porary diet  in  traveling,  etc.  A  fresh  can  should  be 
opened  daily.  It  can  be  diluted  with  three  to  six  or  more 
parts  of  water,  or  cereal  water  and  sugar  in  some  form 
as  indicated;  however,  the  carbohydrates  contained  in 
the  formula  should  rarely  exceed  7  per  cent.  One  part 
of  milk  to  two  parts  of  diluent  plus  carbohydrates  is  the 
strongest  formula  in  which  it  is  ever  necessary  to  feed 
infants,  as  this  equals  the  strength  of  whole  milk  with 
carbohydrate  added. 

Occasionally,  infants  with  a  very  weak  digestion  will 
thrive  on  the  evaporated  milk  where  all  other  methods 
fail,  if  the  food  is  started  in  high  dilution,  the  quantity  be- 
ing increased  as  the  infant  shows  improved  capacity. 

Because  of  the  repeated  heating  and  the  low  salt  con- 
tent, the  food  necessarily  loses  some  of  its  vital  require- 
ments, and  an  early  attempt  to  change  to  fresh  milk 
should  be  made  in  order  to  avoid  constitutional  disorders 
as  rachitis,  scurvy,  etc.  The  tendency  to  become  very 
fat  on  this  class  of  foods  is  proverbial,  but  this  is  not 
usually  associated  with  high  resistance  or  immunity  to 
infections,  and  these  infants  succumb  rapidly  to-  the 
respiratory  and  intestinal  infections.  Unless  the  mother 
is  forewarned,  it  is  often  with  reluctance  that  she  can  be 
made  to  foresee  the  necessity  of  taking  her  baby  off  the 
food  which  agrees  with  it,  and  experiment  with  a  new 
and  occasionally  uncertain  formula. 


APPENDIX.  279 

The  Pozcdcred  Milk  Foods.  Mammala,  Honor  Brand, 
and  Merrill-Soule  Brand  are  fresh  milk  dried.  In  the 
two  former,  part  of  the  cream  has  been  removed.  All 
have  some  lactose  added.  They  find  their  most  impor- 
tant indication  as  an  occasional  substitute  feeding  in 
breast-fed  infants — first,  for  the  mother's  convenience, 
to  allow  her  recreation ;  secondly,  where  the  milk  of  the 
mother  is  insufficient,  and  one  or  two  regular  feedings 
are  indicated  temporarily  until  a  formula  of  fresh  milk 
is  advisable,  or  while  traveling,  when  the  milk  supply  is 
uncertain;  and  thirdly,  those  containing  large  amounts 
of  maltose  (Horlick's)  can  be  given  once  daily  in  breast- 
fed infants  in  need  of  a  laxative. 

The  Second  Class.  Those  to  be  used  in  conjunction 
with  fresh  cow's  milk.  In  this  class  belong  Groups  III 
and  IV.    These  give  us  a  far  more  rational  infant  food. 

Group  III.  (A)  The  unchanged  or  partially  dextrin- 
ized  starches  are  especially  to  be  used  in  solution  in  place 
of  boiled  water  as  diluents,  best  after  the  second  month. 
A  number  of  good  cereal  flours  can  be  purchased  on  the 
market. 

(B)  In  this  group  are  found  most  of  the  highly  ad- 
vertised and  detailed  baby  foods.  They  have  little  or 
no  advantage  over  the  plain  cereal  flours. 

(C)  These  are  especially  valuable  where  maltose  and 
dextrin  are  better  taken  than  cane-  or  milk-  sugar.  Dex- 
tri-maltose  (Mead's  No.  1  and  2)  and  Nahrzucker. 

DIRECTIONS    FOR    THE    PREPARATION 
OF    INFANT'S    FOODS. 

Tea. 

To  a  small  half-teaspoonful  of  fennel,  chamomile,  or 
''green"  tea  add   1  pint  of  boiling  w^ater,  cover  with  a 


280  INFANT   FEEDING. 

clean  dish,  and  steep  for  two  o^r  three  minutes,  or  till  the 
tea  is  of  a  light  yellow  color ;  then  pour  through  a  clean 
sieve  or  muslin.  It  should  be  weak.  If  used  for  thirst 
only,  in  diarrheal  cases,  one-fourth  of  the  above  amount 
is  sufficient. 

Barley  Water. 

Soak  1  tablespoonful  of  washed  barley  (pearl)  in 
water  overnight;  pour  off  water,  add  1  quart  of  fresh 
water,  and  boil  down  to  1  pint  (2  hours).  Add  boiled 
water  to  make  1  pint,  if  necessary.  Strain  through  fine 
cloth.     Keep  in  ice-chest. 

Oatmeal  and  Rice  Water. 

They  are  prepared  in  the  same  manner,  only  boiled 
•more  slowly.  They  may  be  made  from  barley,  oatmeal, 
or  rice  flours  by  using  1  rounded  tablespoonful  to  1^ 
pints  of  water,  and  boiling  for  20  minutes  down  to  1 
pint,  in  an  open  stew-pan,  stirring  constantly.  (Ap- 
proximates 3  calories  per  ounce.) 

Oatmeal,  Barley,  and  Wheat  Jelly. 

Use  twice  the  quantity  of  cereal  and  same  quantity  of 
water. 

To  Dextrinize  Barley  or  Oatmeal  Water. 

Cool  to  105°  F.,  add  1  teaspoonful  extract  of  malt, 
cereo,  liquid  taka-diastase  or  diazyme,  stir,  allow  to 
stand  for  15  minutes,  when  the  gruel  becomes  thin  and 
watery.  Add  a  pinch  of  salt,  stir,  only  to  mix,  cool, 
strain,  and  put  in  ice-chest. 


APPENDIX.  281 

Flour  Ball. 

Tie  2  pounds  of  wheat  flour  in  a  cheese-cloth  bag,  and 
boil  in  2  quarts  of  water  for  five  hours.  Remove  from 
water;  place  in  oven  until  quite  brown  on  the  outside. 
This  will  require  from  two  to  three  hours  slow  baking. 
Break  open  and  throw  away  the  brown  shell;  the  re- 
mainder, the  baked  flour,  must  then  be  grated  into  a 
powder,  or  may  be  ground  in  a  mill. 

Albumin  Water. 

To  Yz  cup  of  cold  boiled  water  add  the  white  of  1  fresh 
^%g  and  a  pinch  of  salt.  Stir  very  thoroughly.  A  piece 
or  two  of  artificial  ice  may  be  added  before  stirring. 
One-half  teaspoonful  of  sugar  and  orange  juice  may  be 
added,  if  not  contraindicated.    Barley  water  may  be  used. 

Albumin  Water  with  Beef  Extract. 

One-quarter  teaspoonful  of  beef  extract  may  be  added 
to  the  cold  water  before  adding  the  tgg  albumin. 

White  of  Egg  and  Digested  Gruel. 

Whites  of  2  eggs  may  be  added  to  1  pint  of  dextrin- 
ized  barley,  oatmeal,  etc.,  gruels.    Stir  thoroughly. 

Pasteurized  Milk  (double  boiler). 

Place  milk  in  cold  water  bath,  having  water  to  level  of 
milk;  bring  milk  to  temperature  between  155°  and 
167°  F.  for  15  to  20  minutes. 

Sterilized  Milk  (double  boiler). 

The  milk  mixture  is  put  into  the  inner  vessel  cold,  and 
the  water  in  the  outer  vessel  is  also  cold,     The  double 


282  .  INFANT    FEEDING. 

boiler  is  then  placed  on  the  stove  and  allowed  to  remain 
until  the  water  in  the  outer  vessel  boils  for  6  to  8  min- 
utes; the  whole  process  requires  10  to  15  minutes. 
While  the  milk  heated  in  this  manner  forms  a  much  finer 
and  softer  curd  than  that  of  raw  milk,  it  is  not  as  fine 
as  the  milk  boiled  directly  over  the  flame. 

Whey. 

Heat  1  quart  of  clean  raw  milk  to  104°  F.,  and  add  1 
level  teaspoonful  of  chymogen  or  fresh  essence  of  pep- 
sin (Fair child's-).  Allow  it  to  stand  for  one-half  hour, 
pour  off  the  free  whey,  pour  the  curd  into  a  straining 
cloth  for  one-half  hour,  and  collect  the  remainder  of  the 
whey. 

Chymogen  Milk. 

Boil  milk  for  five  minutes,  cool  to  104°  F.,  and  add  1  full 
teaspoonful  of  chymogen  to  each  quart  of  milk,  and  stir 
for  one-half  minute.  Let  it  come  to  a  clabbard  by  allow- 
ing it  to  stand  for  15  minutes;  then  beat  it  well  until  the 
curd  is  finely  divided.  Do  not  heat  above  100°  F.,  when 
preparing  individual  bottles  for  feeding,  otherwise  curds 
will  clump,  and  will  not  pass  through  the  nipple. 

Indications  for  chymogen  milk :  ( 1 )  Vomiting  in  in- 
fancy; (2)  indigestion  due  to  the  large  curd  formation. 

Buttermilk  in  the  Home. 

A  pure  culture  of  lactic  acid  bacilli  is  added  to  raw, 
pasteurized,  or  boiled  milk  in  an  earthenware  dish,  and 
allowed  to  stand  at  about  80°  F.  for  15  to  20  hours,  or 
until  the  casein  is  coagulated.  Stir  vigorously  in  a  churn, 
or  with  a  spoon  or  egg-beater  until  the  curd  is  very  small, 
and  then  push  the  contents  through  a  fine  wire  strainer 


APPENDIX.  283 

with  a  spoon.  If  the  buttermilk  is  too  thick,  add  a  small 
amount  of  water.  When  the  buttermilk  is  once  made, 
a  small  portion  (about  4  ounces)  may  be  used  as  the  in- 
oculating agent  for  the  next  supply  to  be  made.  In  this 
way  the  original  culture  may  be  made  to  last  from  six 
to  eight  weeks.  The  quality  and  action  of  the  product 
made  will  vary  but  little.  Add  4  ounces  of  buttermilk  to 
1  quart  of  fresh  milk,  incubate,  and  follow  the  above 
outline.  Sometimes  the  milk  will  not  coagulate,  although 
it  may  smell  sour.  Stirring  with  a  spoon  will  often  pro- 
duce coagulation  in  a  few  minutes.  The  fat  present  will 
rise  to  the  top,  and  when  coagulated  appears  as  a  brown- 
ish-yellow scum,  which  may  be  removed  before  the  curd 
is  broken  up.  At  the  present  time  the  market  is  flooded 
with  tablets  for  the  preparation  of  buttermilk,  but  one 
must  hesitate  before  using  them  to  prepare  milk  for  a 
baby.  A  pure  culture  should  be  used,  or  one  recom- 
mended by  the  physician.  Whole  or  skim  milk  is  to  be 
used  as  indicated  in  each  individual  case. 

Startoline. 

Carefully  pasteurize  2  quarts  of  fresh  whole  milk  to  a 
temperature  of  180°  F.  for  one  hour,  or  boil  for  five 
minutes ;  cool  quickly  to  about  80°  F.,  and  add  1  ounce 
of  Hanson's  Lactic  Ferment  Culture,  and  let  it  stand  un- 
disturbed until  well  curdled,  which  should  be  in  15  or  20 
hours,  at  a  temperature  of  75°  F.  Then  place  on  ice. 
When  ready  to  use,  beat  curd  up  with  a  spoon  until  it  is 
of  a  creamy  consistency. 

Buttermilk  for  Hospital  Feeding. 

Pasteurize  whole  sweet  milk  to  a  temperature  of  180° 
F.  for  one  hour ;  then  place  in  cold  water  until  cooled  to 


284  INFANT   FEEDING. 

80°  F.  Add  1  ounce  of  startoline  to  every  quart  of  milk, 
stir  with  a  spoon,  and  cover;  allow  to  stand  from  15  to 
20  hours,  then  churn  for  one  hour ;  then  add  a  little  cold 
sterile  water  to  break  butter  away  from  milk;  and  strain 
buttermilk. 

Buttermilk  and  Skim  Milk  Mixture. 

To  a  few  tablespoonfuls  of  buttermilk  add  2^  level 
tablespoonfuls  of  f^our  (flour  ball  or  dextrinized  barley 
flour),  to  make  a  paste.  ]\Iake  up  to  1  quart  with  but- 
termilk. (1)  Bring  to  a  boil,  withdraw  from  fire.  (2) 
Bring  to  a  boil,  withdraw  from  fire  a  second  time.  (3) 
Add  4  level  tablespoonfuls  of  cane-sugar,  and  bring  to  a 
boil  for  the  third  time.  (^Maltose-dextrin  preparations 
are  best  in  all  diarrheal  conditions.)  (1,  2,  and  3  should 
require  about  twenty  minutes  time.)  Make  up  to  1  quart 
with  boiled  water,  if  it  has  boiled  away;  put  on  ice.  It 
is  well  to  start  with  one-half  the  amount  of  sugar,  and 
increase  as  indicated. 

Brady's  Buttermilk  Mixture  No.  1. 

Dr.  Jules  Brady,  of  St.  Louis,  has  suggested  the  two 
buttermilk  mixtures  following,  which  contain  less  car- 
bohydrates than  the  above  buttermilk  mixture,  and  which 
he  has  found  especially  valuable  in  the  feeding  of  infants 
in  institutional  practice. 

Mixture  No.  1,  which  is  used  for  young  infants  during 
the  first  two  months,  contains  11  calories  in 'each  ounce; 
the  young  infant  receives  4  ounces  of  this  mixture  for 
every  pound  of  bod}^  weight  as  soon  as  it  will  take  it. 
The  baby  weighing  6  pounds  at  birth  is  allowed  to  take 
24  ounces  in  twenty-four  hours,  or  3.S  ounces  every  three 


APPENDIX.  285 

hours,  7  feedings  in  twenty- four  hours.  The  average  in- 
fant at  three  or  four  days  will  take  1  ounce;  at  eight 
days,  1  to  2  ounces;  at  fourteen  days,  1^  to  2  ounces; 
at  three  weeks,  2  ounces ;  at  six  weeks,  3  ounces ;  at  eight 
weeks,  4  ounces. 
Mixture  No.  i. 

Ya,  quart  skim  milk. 

Ya^  quart  barley  water  (thick). 

1  ounce  by  measure,  Mellin's  Food. 

Yz  ounce  granulated  sugar. 
The  ingredients  are  mixed  together  in  the  following 
manner:  To  the  barley  gruel  is  added  the  cane-sugar 
and  the  Mellin's  Food,  and  then  the  buttermilk  is  slowly 
added,  and  the  mixture  strained.  Note  that  the  butter- 
milk is  not  boiled.  The  mixture  is  rather  thick,  and  has 
the  sour  taste  of  buttermilk.  As  a  rule,  the  milk  is  acidi- 
fied with  lactic  acid  bacilli  twelve  hours  before  being 
made  up,  having  first  agitated  it. 

Brady's  Buttermilk  Mixture  No.  2. 

On  reaching  a  weight  of  8}^  to  9  pounds,  infants  re- 
ceive the  mixture  No.  2,  which  contains  18  calories  for 
every  ounce.     The  babies  are  allowed  3  ounces  of  the 
mixture  No.  2  for  every  pound  of  body  weight. 
Mixture  No.  2. 

%  quart  whole  milk. 
%  quart  barley  water  (thick). 
1  ounce  granulated  sugar. 
Indications  for  buttermilk  and  skim  milk  mixtures : 

1.  Fat  indigestion. 

2.  Loose  bowels  (it  may  be  necessary  to  reduce  the 

amount  of  sugar.     The  high  protein  contents 
tends  to  constipate). 

3.  Malnutrition,   with   stationary   weight. 


286  INFANT   FEEDING. 

Keller's  Malt  Soup. 

To  11  ounces  (330  Gm.)  of  warm  milk  gradually  add 
1%  ounces  (50  Gm.)  of  flour,  stir  constantly,  then  pour 
through  a  clean  sieve  or  muslin.  In  another  dish  dis- 
solve 3  ounces  (100  Gm.)  by  weight,  or  2}4  ounces  or 
tablespoonfuls  by  measure,  of  Borcherdt's  malt  extract 
with  potassium  carbonate  in  20  ounces  (600  Gm.)  of 
boiled  warm  water.  Then  mix  both  solutions,  put  on 
fire,  stir  continually,  and  boil  for  two  or  three  minutes. 

IndicaHons  for  Keller's  Malt  Soup : 

1.  Fat  indigestion. 

2.  Disturbed  metabolic  balance   (fat-soap  stools). 

3.  Chronic   constipation    (often   relieved   by    simple 

addition  of  malt  soup  extract  to  ordinary  milk 
mixture  in  place  of  part  of  sugar). 
C  ontvaindications : 

1.  Before  the  third  month,  if  the  stools  are  loose. 

2.  For  a  period  of  more  than  four  to  eight  weeks 

(to  be  followed,  where  possible,  by  ordinary 
milk  mixtures,  the  strength  of  the  latter  being 
gradually  increased). 

Cream  Soups. 

Cream  soups  may  be  made  from  vegetable  pulp,  using 
1  tablespoonful  of  cooked  potatoes,  peas,  or  asparagus  to 
^  cup  of  water  in  which  the  vegetables  were  cooked,  ^ 
cup  of  sweet  milk,  and  Yz  teaspoonful  of  flour,  with  a 
little  butter  and  salt.  Cook  another  minute  or  two. 
Strain  if  necessary.     Serve. 

Corn  or  tomatoes  may  be  used  in  the  same  manner, 
using  2  tablespoonfuls  of  strained  vegetables,  with 
about    one-third    water    and    two-thirds    milk.       When 


APPENDIX.  287 

tomatoes  are  used,  add  a  small  pinch  of  soda  to  tomatoes 
before  adding  other  ingredients. 

Vegetable  Soup. 

One-fourth  pound  lamb  stew,  cut  into  pieces,  1  potato 
cut  into  pieces,  1  carrot  cut  into  pieces,  2  stalks  of  celery 
cut  into  pieces,  1  tablespoonful  of  pearl  barley,  2  table- 
spoonfuls  rice,  2  quarts  water.  Boil  down  to  1  quart; 
boil  three  hours.  Add  pinch  of  salt,  and  strain  before 
feeding. 

Lamb,  or  Veal  Broth. 

Lean  meat  chopped  fine,  1  pound ;  cold  water,  1  quart ; 
a  pinch  of  salt ;  cook  slowly  two  or  three  hours  to  1  pint. 
Add  water  from  time  to  time,  so  that  when  finished  there 
will  be  1  pint  of  broth.     Strain;  when  cold,  skim  off  fat. 

Chicken  Broth. 

Small  chicken,  or  one-half  of  large  fowl,  with  all  skin 
and  fat  removed ;  chop  bones  and  all  into  small  pieces ;  add 
1  quart  boiling  water  and  a  little  salt;  cover  closely,  and 
allow  to  simmer  over  a  slow  fire  for  two  hours.  After 
removing  allow  to  stand  one  hour;  then  strain.  Add 
water,  if  necessary,  from  time  to  time,  so  that  there  will 
be  1  pint  when  finished. 

Farina  Soup. 

To  1  pint  of  meat  broth,  gradually  add,  while  stirring, 
1  even  tablespoonful  of  farina,  and  boil  down  to  1  cup 
(^  pint)  in  about  twenty  minutes.  It  is  a  good  plan  to 
boil  the  farina  for  from  fifteen  to  twenty  minutes  before 
adding  it  to  the  broth ;  then  broth  and  farina  need  to  be 
boiled  together  for  but  ten  minutes. 


288  INFANT   FEEDING. 

Dried  Fruit  Soup. 

Wash  thoroughly  1  cup  of  dried  apricots  and  1  cup  of 
prunes.  Cook  in  1  quart  of  cold  water  until  very  soft. 
Strain  and  press  out  all  juice.  Sweeten  to  taste.  Thicken 
with  a  tablespoonful  of  rice  flour  to  1  quart  of  the  liquid. 
Cook  twenty  minutes  to  remove  the  raw  taste  of  the 
flour. 

Soy  Bean  and  Condensed  Milk  (Ruhrah). 

Add  a  level  tablespoonful  of  soy  bean  flour  to  2  level 
tablespoonfuls  of  barley  flour,  add  a  pinch  of  salt,  and 
mix  to  a  paste  with  boiled  water,  adding  further  water  to 
1  quart.  Boil  for  twenty  minutes,  and  add  water  to  make 
up  for  the  loss  due  to  evaporation  during  boiling,  so  that 
total  mixture  is  1  quart.  Condensed  milk  is  now  added, 
varying  in  quantity  from  y^  to  \  dram  of  condensed 
milk  to  each  ounce  of  the  mixture,  depending  upon  the 
age  and  the  condition  of  the  infant.  Double  the  quantity 
of  soy  bean  and  barley  flours  may  be  used  for  older  chil- 
dren. Each  ounce  of  soy  bean  gruel  contains  10  grams  of 
protein  and  102  calories.  Two  ounces  of  soy  bean  gruel 
in  a  quart  of  water  contains  0.56  per  cent,  protein,  0.62 
per  cent,  fat,  and  3.31  per  cent,  sugar. 

The  quantity  of  the  feedings  may  be  varied  according 
to  the  condition  and  needs  of  the  infant,  varying  from  1 
to  8  ounces  per  feeding. 

It  is  indicated  whenever  fresh  clean  milk  is  not  ob- 
tainable, in  infants  with  marasmus,  in  some  intestinal 
disturbance  associated  with  diarrhea. 

Beef  Juice. 

Take  %  to  ^2  pound  round  steak,  broil  slightly,  cut 
into  small  pieces,  and  then  press  out  the  juice  with  a  meat 


APPENDIX.  289 

press  or  potato  ricer,  and  add  a  small  pinch  of  salt.  Feed 
fresh,  or  warm  before  giving,  but  do  not  heat  sufficiently 
to  coagulate  albumin. 

Potatoes. 

Boil  potatoes  in  salt  water  in  the  ordinary  way  until 
they  are  thoroughly  done.  Then  mash  through  a  very 
fine  sieve,  and  add  a  little  butter. 

Spinach. 

Cook' spinach  in  salted  water  until  tender.  Pour  cold 
water  over  it,  and  drain.  Chop  fine,  or  rub  through  a 
coarse  sieve.  To  2  tablespoonfuls  of  spinach  add  1  tea- 
spoonful  of  fine  breadcrumbs,  y^  teaspoonful  melted  but- 
ter, and  a  little  salt.    Reheat  and  serve. 

Asparagus. 

Cook  one-half  of  a  bunch  of  asparagus  in  about  a  pint 
of  slightly  salted  water.  When  tender,  remove  stalks  one 
by  one.  Place  on  a  warm  plate,  and  remove  pulp  by 
taking  hold  of  the  firm  end  of  the  stalk,  scraping  lightly 
with  a  fork  towards  the  tips.  Use  pulp  only.  Make  a 
sauce  with  one-fourth  of  a  cup  of  water  in  which 
asparagus  was  cooked,  one-fourth  of  a  cup  of  milk,  1 
teaspoonful  flour,  a  little  butter  and  salt.  Dip  a  small 
piece  of  toast  in  the  sauce.  Take  what  is  left  of  the 
sauce  and  mix  with  2  tablespoonfuls  of  asparagus  pulp. 
Reheat.    Place  on  toast  and  serve. 

Carrots. 

Cook  ^  pound  of  young  carrots  in  a  pint  of  fat-free 
soup  stock  or  slightly  salted  water,   adding  more  if  it 

19 


290  INFANT   FEEDING. 

cooks  away  before  they  are  done.  Rub  through  a  sieve ; 
add  1  teaspoonful  of  bread-crumbs,  a  Httle  butter  and 
salt.     Reheat  and  serve. 

Beans. 

Soak  2  ounces  or  4  tablespoonfuls  of  beans,  and  cook 
them  slowly  in  a  good  deal  of  water  until  they  are  soft, 
but  not  broken.  Rub  through  a  sieve,  add  1  cupful  of 
soup  stock,  and  let  them  cook  for  one-half  hour,  adding 
more  stock  if  it  boils  away.  Mix  a  little  butter  and  flour, 
about  a  teaspoonful  of  each,  and  a  little  salt.  Add  to 
soup.    Return  to  fire,  and  cook  for  a  few  minutes. 

Green  Peas. 

Cook  a  cupful  of  green  peas  in  boiling  salted  water 
until  they  are  done.  Drain,  saving  the  water  in  which 
they  are  cooked.  Rub  through  a  coarse  sieve.  Make  a 
sauce  of  2  tablespoonfuls  of  water  in  which  the  peas 
were  boiled,  2  tablespoonfuls  of  sweet  milk,  i^  teaspoon- 
ful flour,  ^  -  teaspoonful  fine  bread-crumbs.  Mix  all 
together.    Reheat  and  serve. 

Fruits. 

(a)  Orange  Juice:  Take  sweet  orange,  cut  into  halves, 
and  squeeze  out  juice  by  hand  or  with  a  lemon  squeezer; 
strain,  put  on  ice,  and  use  as  ordered. 

(b)  Prune  Juice:  Take  ^  pound  of  prunes,  wash 
thoroughly,  cover  with  cold  water,  and  soak  overnight. 
In  the  morning  place  on  stove  in  the  same  water,  and 
cook  until  tender.  Add  1  teaspoonful  of  sugar,  and 
strain. 

(c)  Prune  Jelly:  Cover  1  pound  of  prunes  with  1 
quart  of  water;  cook  slowly  until  tender;  pit,  and  press 


APPENDIX.  291 

pulp  through  a  sieve.  Add  sugar  to  sweeten  (2  tea- 
spoonfuls)  and  Yz  box  of  gelatin  dissolved  in  a  pint  of 
water,  and  boil.     Strain,  cool,  and  keep  covered. 

(^)  Apple  Sauce:  Take  6  apples  and  peel,  core,  and 
cut  them  into  quarters.  Place  them  in  an  enameled  dish ; 
sprinkle  over  them  1  tablespoonful  of  sugar;  add  1  cup 
of  cold  water;  put  the  dish  on  the  stove,  and  boil  the 
apples  to  a  mush  (about  thirty  minutes). 

{e)  Orange  Gelatin:  Soak  ^  box  of  shredded  gelatin 
in  cold  water  for  thirty  minutes.  Add  2  cupfuls  of  boil- 
ing water,  and  dissolve.  Then  add  1  cupful  of  sugar, 
the  juice  of  1  lemon,  and  a  cupful  of  orange  juice. 
Strain  through  a  fine  strainer  (or  a  cloth)  into  moulds, 
and  set  away  to  harden. 

Eggs. 

Use  only  soft-boiled  or  poached  eggs.  Be  sure  that 
the  eggs  are  fresh.  Drop  tgg  in  boiling  water;  imme- 
diately turn  flame  out,  and  allow  to  stand  for  five 
minutes. 

Pap. 

Put  1  pint  of  milk  on  to  boil;  add  butter  the  size  of  a 
walnut.  Beat  1  tgg  thoroughly.  When  milk  boils,  add 
the  beaten  ^gg,  stirring  constantly.  Mix  1^  tablespoon- 
fuls  flour  into  a  paste  and  add  to  mixture,  stirring  con- 
stantly. Allow  mixture  to  boil  ten  minutes.  Just  before 
taking  from  the  fire  add  a  pinch  of  salt.  May  be  taken 
plain,  or  with  milk  and  sugar  as  directed. 

Cornstarch  Pudding. 

Take  1  pint  of  milk  and  mix  with  2  tablespoonfuls  of 
cornstarch;    cane-sugar,     1    tablespoonful.      Flavor    to 


292  INFANT   FEEDING. 

taste;  then  boil  the  whole  eight  minutes.    Allow  to  cool 
in  a  mould. 

Custard  Pudding. 

Break  1  tgg  into  a  teacup  and  mix  thoroughly  with 
sugar  to  taste.  Then  add  milk  to  nearly  fill  the  cup. 
Mix  again,  and  tie  over  the  cup  a  small  piece  of  linen. 
Place  the  cup  in  a  shallow  saucepan  half  full  of  water, 
and  boil  for  ten  minutes. 

If  it  is  desired  to  make  a  light  batter  pudding,  a  tea- 
spoonful  of  flour  should  be  mixed  in  with  the  milk  be- 
fore tying  up  the  cup. 

Infant's  Gelatin  Food. 

About  1  teaspoonful  of  gelatin  should  be  dissolved  by 
boiling  in  ^  pint  of  water.  Toward  the  end  of  the  boil- 
ing, ^  pint  of  cow's  milk  and  1  teaspoonful  of  arrow- 
root (made  into  a  paste  with  cold  water)  are  to  be 
stirred  into  the  solution,  and  1  to  2  tablespoonfuls  of 
cream  added,  just  at  the  termination  of  the  cooking.  It 
is  then  to  be  moderately  sweetened  with  white  sugar, 
when  it  is  ready  for  use.  The  whole  preparation  should 
occupy  about  fifteen  minutes. 

Albumin  or  Eiweiss  Milk  (Finkelstein). 

One  quart.  Take  fresh  whole  milk,  bring  to  a  tem- 
perature of  98°  to  100°  F.  Then  add  2  level  tablespoon- 
fuls of  chymogen  powder  to  a  quart  of  milk;  place  in  a 
water  bath  of  107°  F.,  for  fifteen  to  twenty  minutes, 
until  coagulated.  Then  hang  in  a  sterile  muslin  bag  for 
one  hour  to  drain. 

To  the  curd  of  1  quart  of  milk  add  1  pint  of  buttermilk, 
and  rub  through  a  copper  gauze   strainer  three  times. 


APPENDIX.  293 

Then  add  2  level  tablespoonfuls  of  wheat  flour,  flour 
ball,  or  imperial  granum,  rubbed  to  a  paste  with  1  pint 
of  water.  Boil  ten  minutes,  cutting  back  and  forth  con- 
stantly, not  stirring,  with  a  large  wooden  spoon,  other- 
wise large  curds  will  form.  If  needed,  water  should 
again  be  added,  when  directed  by  the  physician.  Finkel- 
stein  advises  the  early  addition  of  3  per  cent,  of  carbohy- 
drate in  the  form  of  a  maltose  dextrin  compound.  This 
is  best  done  by  dissolving  the  sugar  in  a  moderate  quan- 
tity of  water,  and  adding  while  the  mixture  is  being 
boiled.  It  must  not  be  heated  above  100°  F.  before  feed- 
ing, otherwise  it  will  clump. 

Albumin  milk  contains :  protein,  3  per  cent. ;  fat,  2.5 
percent.;  milk-sugar,  1.5  per  cent.;  starch,  1.0  per  cent.; 
salts,  0.5  per  cent.  Caloric  value  is  450  calories  per  liter, 
or  12  calories  per  ounce. 

Indications  for  albumin  milk   (Finkelstein)  : 

1.  Diarrheas  and  all  cases  of  abnormal  intestinal  fer- 

mentation (sugar). 

2.  Fat  indigestion  with  low  sugar  tolerance. 

3.  Gastro-intestinal   infections   associated   with   fre- 

quent stools. 

4.  Systemic  infections  with  intestinal  complications. 

Albumin  Milk  (Miiller  and  Schloss). 

Use  1  quart  of  water  and  1  quart  of  buttermilk,  and 
boil  for  three  minutes.  Set  aside  for  thirty  minutes,  and 
then  pour  off  the  upper  36  ounces  of  the  whey.  Boil  the 
upper  4.5  ounces  of  a  quart  of  fresh  milk  for  three  min- 
utes. Add  1  ounce  of  dextri-maltose  to  the  boiled  top 
milk,  and  to  this  add  the  curds  from  the  first  mixture, 
which  would  equal  27.5  ounces,  making  1  quart  of  the 
milk  mixture. 


294 


INFANT   FEEDING. 


Larosan  Milk. 

Two-thirds  of  an  ounce  of  Larosan  powder  (p. 
276)  is  added  to  5^  pint  of  milk,  and  mixed  thoroughly. 
Another  whole  pint  of  milk  is  heated  to  the  boiling  point. 
\Mien  it  has  come  to  a  boil,  it  is  added  to  the  Larosan 
milk  mixture,  and  the  whole  is  placed  on  the  flame  and 
allowed  to  boil  "for  five  minutes.  This  may  be  diluted 
with  water  in  the  proportion  of  one-half  Larosan  milk 
and  one-half  water,  or  two-thirds  Larosan  milk  and  one- 
third  water. 


Fig.  16.— Utensils  needed  for  artificial  feeding :  Double 
boiler  (small)-,  pan,  funnel,  bottle-brush,  250-mil  (8  oz.) 
graduated  glass  or  pitcher,  6  nursing  bottles  and  rack, 
paper  caps  for  bottles  (sterile),  nipples,  milk,  sugar,  flour, 
milk  magnesia,  citrate  of  soda,  tablespoon,  dairy  ther- 
mometer, \-egetable  mill. 

This  mixture,  because  of  its  high  protein  content  and 
comparative  ease  of  preparation,  can  be  used  as  a  substi- 
tute for  albumin  milk  in  the  home. 


Meats. 

Raw  or  slightly  cooked  beef,  scraped  and  seasoned, 
can  be  fed  in  amounts  equaling  a  tablespoonful  at 
eighteen  months  or  sooner,  once  daily. 


APPENDIX.  295 

Take  meat,  preferably  from  the  round,  free  from  fat. 
Place  on  a  board  and  scrape  with  a  silver  spoon.  When 
you  have  the  desired  amount  of  meat  pulp,  shape  into  a 
pat  and  broil  on  a  hot,  dry  spider.  Do  not  cook  too  long. 
When  done,  season  with  a  little  salt  and  butter.  Serve. 
A  few  drops  of  lemon  juice  may  be  added. 

Later,  lamb,  beefsteak,  roast  beef  and  chops  are  the 
best,  and  should  be  broiled.  By  no  means  fry  any  meat 
for  the  baby.  Soup  meat,  well  cooked,  may  also  be  given. 
All  meats  should  be  very  finely  cut  before  giving  them 
to  children. 

BOTTLES    AND    NIPPLES    AND    THEIR    CARE. 

The  nursing  bottle  should  be  of  such  a  construction 
that  every  portion  of  it  is  easily  reached  with  a  proper 
brush.  This  necessitates  the  avoidance  of  sharp  corners 
and  angles,  and  makes  the  smooth  stream  'lines  in  its 
construction  desirable.  It  should  be  made  of  good  glass, 
not  easily  broken,  capable  of  being  boiled  repeatedly 
without  cracking,  and  should  hold  about  8  to  10  ounces. 
Several  nursing  bottles  should  be  kept  on  hand,  and,  if 
possible,  as  many  bottles  as  there  are  nursings  in  a  day 
should  be  available,  so  that  the  whole  day's  feeding  may 
be  prepared  according  to  the  particular  formula,  and  the 
mixture  then  iced,  and  the  individual  bottles  warmed  on 
a  water-bath  whenever  necessary.  New  bottles  should 
be  annealed  by  placing  them  in  a  vessel  with  cold  water, 
and  then  bringing  the  water  to  a  boil,  boihng  for  twenty 
minutes,  and  then  leaving  the  bottles  in  this  water  until 
it  will  cool  off  again.  Bottles  thus  treated  do  not  crack 
so  easily  when  hot  fluids  are  poured  into  them.  After 
nursing,  the  bottle  should  immediately  be  rinsed  with 
cool  water,  and  then  washed  with  hot  water  and  soap 


296 


INFANT   FEEDING. 


suds  by  means  of  a  bottle  brush.  Afterwards  the  bottle 
should  be  set  aside,  inverted,  so  as  to  drain.  Before  use, 
the  bottles  should  be  boiled  for  five  minutes.  To  avoid 
cracking,  they  must  be  placed  in  cold  water  and  heated 
slowly.  After  the  food  has  been  prepared,  the  individual 


Fig.  17. — Good  and  bad  nursing  bottles.  1.  Ordinary 
small-neck  nursing  bottle  as  sold  in  drug  stores  (8-ounce). 
2.  Improved  large-neck  nursing  bottle  (made  in  5-  and  10- 
ounce  size).    3.  Hygiea  nursing  bottle. 

bottles  may  be  filled  and  stoppered  with  sterile  cotton,  or, 
better,  sterile  paper  caps,  which  are  sold  for  this  purpose. 
Nipples  that  can  be  turned  inside  out  and  easily 
cleansed  should  be  selected.  The  conical  shaped  nipple  is 
preferable.  The  hole  in  the  nipple  should  be  of  such  size 
that  the  milk  will  drop  rapidly  and  not  flow  when  the 
bottle  is  inverted.     New  nipples  should  be  boiled  before 


APPENDIX.  297 

they  are  used.  After  using,  every  nipple  should  imme- 
diately be  washed  with  soap  and  water,  being  turned  in- 
side out,  boiled  and  finally  dropped  into  a  sterile  jar, 
where  it  is  to  be  kept  dry  until  ready  for  use  again. 
Keeping  the  nipples  dry  lengthens  the  life  of  the  rubber. 
Several  nipples  should  always  be  kept  on  hand. 


Fig.  18. — A  milk  station  consisting  of  three  rooms.  Room 
1.  For  all  used  bottles,  bottle  washers,  and  steam  bottle 
sterilizers.  Room  2.  A  clean  room  for  preparation  of  for- 
mulae. This  room  also  contains  milk  separator,  fat-test- 
ing apparatus  and  butter  churn.  Room  3.  Pasteurizing  and 
sterilizing  apparatus. 

CARE    OF    FOOD    DURING   TRAVELING. 

Whenever  possible,   the   baby   should   be   kept   on   its 
usual  diet  during  the  long  journey.    This  is  usually  ac- 


298  INFANT   FEEDING. 

complished  without  much  difficulty  when  the  baby  is  on 
boiled  milk.     If  it  has  been  fed  on  a  raw  milk  mixture, 
the  milk  must  be  boiled  before  starting.     When  for  any 
reason  it  is  impractical  to  carry  the  milk  mixture,  evap- 
orated milk  or  powdered  milk  may  be  used.     (See  Pro- 
prietary Infant  Foods,  p.  273.)     In  the  use  of  evaporated 
milk,  a  fresh  can  must  be  opened  at  least  once  daily. 
When   it   is   known  that  the   baby's    formula   is   to   be 
changed,  it  should  be  tried  out  on  the  new  food  before 
starting  on  the  journe}'.     As  soon  as  possible,  the  pre- 
vious diet  should  be  re-established.  All  water  given  to  the 
baby  while  traveling  must  be  boiled.    The  infant's  food, 
after  boiling  for  at  least  ten  minutes,  should  either  be 
placed  in  individual  nursing  bottles,  or  in  bottles  holding 
not  more  than  1  pint,  so  that  not  more  than  two  or  three 
feedings   should   be  given    from   a    single   bottle.      The 
bottle  should  be  packed  in  ice,  using  care  so  that  none  of 
the  ice  reaches  the  top  of  the  bottle.   Upon  reaching  the 
train  they  should  be  placed  in  the  ice-box  of  the  dining 
or  buffet  ca,r,  unless  a  private  ice-box  is  available.     The 
baby's  bottle  can  be  warmed  on  the  train  by  setting  in  a 
dipper  of  warm  water,  which  may  be  carried  hot  in  a 
thermos  bottle,  if  the  journey  is  to  be  a  short  one.     Care 
must  be  taken  that  the  water  be  not  too  hot,  otherwise  the 
cold  bottles  will  be  cracked.     The  nipples  may  be  carried 
in  a  wide-mouthed,  well-corked  bottle,  sufficient  to  cover 
the  individual  feedings.     The  nipples  and  bottles  should 
be  cleansed  immediately  after  use. 

THE    DIAPER. 

The  diaper  should  be  made  of  soft,  Hght,  and  ab- 
sorbent material,  such  as  cotton  diaper  cloth,  which  can 
be  purchased  for  this  purpose.    Cotton-flannel  is  too  little 


APPENDIX.  299 

absorbent,  and  soon  becomes  hard  as  a  result  of  washing. 
A  second  diaper  may  be  folded  into  a  square,  and  be 
laid  under  the  hips  to  prevent  the  moisture  from  reach- 
ing the  clothes,  or  instead  of  this  arrangement,  which  is 
rather  heating  and  bulky  for  summer  use,  a  small  diaper 
may  be  folded  two  or  three  times  to  form  a  square  of 
about  nine  inches,  and  this  may  be  placed  inside  of  the 
larger  diaper  to  receive  the  urine  and  feces.  About  four 
dozen  diapers  are  needed  for  an  average  baby. 

A  rubber  or  waterproof  cover  should  never  be  applied 
outside  the  diaper.  It  is  very  heating,  and  liable  to  pro- 
duce chafing  and  eczema.  Diapers  should  be  changed  as 
soon  as  soiled,  except  at  night,  when  they  should  be 
changed  when  the  child  is  awakened  for  feeding,  or 
when  it  is  awakened  by  its  own  discomfort.  Soiled 
diapers  are  always  a  somxe  of  discomfort,  and  not  infre- 
quently the  cause  of  severe  irritation  of  the  skin,  as  well 
as  of  infections  of  the  genital  and  urinary  tracts.  This 
is  especially  true  in  the  case  of  female  infants.  No  diaper 
should  be  applied  a  second  time  without  first  being 
washed.  All  diapers  which  have  been  soiled  by  dis- 
charges from  the  bowel  should  have  the  bulk  of  the  feces 
removed  from  the  diaper,  and  should  be  immediately 
washed  with  soap  not  too  alkaline  in  character,  and  later 
boiled  for  twenty  minutes,  and  thoroughly  rinsed,  so  that 
all  alkali  may  be  removed.  They  should  then  be  aired 
thoroughly.  Soda  and  washing-powders  should  be 
avoided  because  of  the  danger  of  irritating  the  child's 
buttock's,  after  being  moistened  by  the  urine. 

The  diapers  of  an  infant  ill  with  an  intestinal  infection 
should  be  cared  for  separately  from  those  of  other  chil- 
dren. After  changing  the  diapers,  the  nurse's  hands  and 
nails  should  be  scrupulously  cleansed  with  brush  and  file. 


300  INFANT   FEEDING. 

BABY'S    DAILY    BATH. 

The  baby  should  be  bathed  at  least  once  a  day,  and  on 
hot  days  even  as  many  as  three  sponge-baths  may  be 
given.  In  the  first  six  months  the  temperature  of  the 
bath  should  be  100°  F.,  and  in  the  second  half  of  the 
year  from  90°  to  95°  F.  The  room  in  which  the  bathing 
is  done  should  have  a  temperature  of  at  least  70°,  and 
not  more  than  75°  F. 

Toward  the  end  of  the  first  year  the  infant  may  be 
sprayed  for  15  to  30  seconds  with  water  at  75°  to  80°  F. 
This  should  be  followed  by  brisk  rubbing  of  the  entire 
body.  In  young  infants  the  bath  is  most  conveniently 
given  before  the  mid-morning  feeding,  and  the  face  and 
hands  may  be  sponged  before  the  6  o'clock  feeding.  In 
older  infants,  a  cool  sponge  and  massage  may  be  given  in 
the  morning,  and  the  warm  bath  at  bedtime. 

Before  the  umbilical  cord  has  separated,  sponge-bath 
only  should  be  given,  and  never  a  submersion  bath,  for 
the  fear  of  infection  of  the  umbilical  stump.  Sponge- 
bath  may  be  given  on  a  towel,  and  when  a  tub-bath  is 
given,  the  child  should  be  allowed  to  rest  upon  the  at- 
tendant's left  arm,  which  is  slipped  under  its  back  from 
the  baby's  right  side.  By  grasping  the  baby  under  the 
armpit  with  the  left  hand  a  good  hold  is  secured,  which 
prevents  slipping.  The  right  hand  is  left  free  for  wash- 
ing the  baby.  A  special  wash-cloth,  preferably  of  cheese- 
cloth, should  be  provided  for  washing  the  baby's  face  and 
head. 

A  pure,  bland,  white  soap  should  be  used.  Very  little 
soap  is  needed  for  cleansing  the  baby's  skin,  and  it  is 
most  important  that  the  skin  should  be  thoroughly  rinsed. 
If  the  skin  is  sensitive  and  easily  irritated,  soap  should  be 
avoided,  and  the  bran-bath   (made  by  putting  a  handful 


APPENDIX.  301 

of  bran  in  cheese-cloth  bag  and  soaking  this  in  the  water 
until  milky)  should  be  used. 

After  the  bath  the  baby  should  be  wrapped  in  a  large 
soft  towel  and  dried  by  sponging,  and  not  by  rubbing. 
Special  attention  should  be  paid  to  folds  and  creases  of 


Fig.  19. — Hospital  bathroom.  Located  between  two  small 
wards  for  infants,  showing  two  metal  water  jackets  rest- 
ing on  a  porcelain  sink.  These  can  be  filled  with  water,  and 
have  a  registering  thermometer  for  indicating  the  tempera- 
ture before  giving  the  bath.  They  are  covered  with  a  clean 
towel  for  each  baby.  Baby  is  showered  from  an  automatic 
mixing  tank,  which  registers  temperature  of  the  water  in 
the  tank.  The  room  further  contains  a  scale  and  a  low 
dressing  table,  with  the  various  dressings,  powders  and 
ointments  to  be  used.  Also  low  nursery  chairs,  collapsible 
bags  for  soiled  linen,  and  waste  basins. 


302  INFANT   FEEDING. 

the  skin,  and  these  should  be  well  powdered  after  being 
thoroughly  dried. 

Only  warm  baths  should  be  used  in  infants  who  be- 
come pale  and  cyanotic  when  a  cooler  bath  is  used. 

Care  should  be  taken  in  bathing  all  children  suffering 
from  coughs.  Great  care  should  also  be  used  while  bath- 
ing a  child  suffering  from  vulvovaginitis,  to  avoid  infec- 
tion of  the  eyes. 

COLD  BATH  AND  COLD  PACK. 

Cold  bath  is  an  efficient  antipyretic  and  nervous  de- 
pressant in  cerebral  irritation,  but  it  is  a  somewhat  severe 
procedure  for  the  infant,  and  is  less  frequently  indicated 
than  in  the  adult.  It  is  to  be  used  only  in  infants  who 
react  well.  The  bath  is  started  with  water  at  100°  F., 
and  the  temperature  is  then  gradually  lowered  by  the 
addition  of  ice-water,  down  to  about  80°  F.  The  infant 
should  be  continually  rubbed  while  in  the  bath.  The 
bath  should  not  be  longer  than  five  to  ten  minutes,  and 
should  be  discontinued  at  once,  if  any  cyanosis  appears. 
The  infant  must  be  dried  quickly,  and  then  wrapped  in  a 
dry  blanket,  without  dressing,  and  put  to  bed. 

In  most  cases,  however,  a  cold  pack  is  preferable  to 
cold  bath,  especially  in  young  infants,  as  the  former  is  a 
somewhat  milder  procedure.  Cold  pack  is  one  of  the  best 
antipyretic  procedures  in  infancy  and  childhood.  The 
naked  child  is  wrapped  in  a  blanket  wrung  out  of  water 
at  a  temperature  of  about  100°  F.,  and  is  then  rubbed 
with  ice  through  the  blanket  for  about  five  to  ten  min- 
utes. Ice-bag  to  head  and  hot-water-bag  to  feet  are  very 
useful — often  necessary.  After  rubbing  with  ice,  the 
child  is  left  in  the  blanket,  and  covered  well.  The  blanket 
may  be  removed,  the  child  dried,  and  put  into  a  dry 
blanket  after  about  one  hour. 


APPENDIX.  303 

HOT    BATH. 

Hot  bath  is  indicated  in  cases  of  collapse  or  shock  as  a 
stimulating  procedure,  and  prolonged  hot  bath  as  a  dia- 
phoretic procedure.  It  should  be  started  with  water  at 
a  temperature  of  100°  F.,  and  the  temperature  gradually 
raised  to  about  105°  F.  by  addition  of  hot  water.  An 
ice-cap  or  cold  cloth  should  be  applied  to  the  head.  A 
thermometer  should  always  be  used  while  giving  a  hot 
bath.  The  infant  should  be  well  rubbed  during  the  bath, 
which  should  be  continued  for  about  ten  minutes.  After 
the  hot  bath  the  infant  should  be  well  dried,  until  the 
skin  is  red,  and  then  wrapped  in  a  blanket  and  put  to  bed. 

MUSTARD  BATH  AND  MUSTARD  PACK. 

Mustard  bath  and  mustard  pack  are  indicated  for  their 
stimulating  effect  in  cases  of  shock  or  collapse,  and  in 
acute  congestion  of  internal  organs,  and  also  in  con- 
vulsions. 

The  amount  of  mustard  used  and  the  temperature  of 
water  is  the  same  in  both  procedures.  Powdered  mus- 
tard, in  quantity  of  about  1  level  tablespoonful  to  each 
gallon,  or  1  teaspoonful  to  each  quart,  when  smaller 
quantities  are  sufficient,  should  be  used.  Full  quantity 
of  mustard  powder  is  first  dissolved  in  about  a  gallon  of 
warm  water,  and  to  this  the  rest  of  the  water  is  added, 
while  preparing  the  bath.  For  giving  the  pack,  a  smaller 
quantity  of  water  is  usually  required.  The  temperature 
of  the  water  should  be  about  100°  F.,  and  it  may  be 
raised  to  about  105°  F.  by  addition  of  hot  water.  Cold 
applications  should  be  made  to  the  head. 

The  bath  should  be  continued  for  about  ten  minutes, 
accompanied  by  rubbing  the  skin,  and  followed  by  ablu- 


304  INFANT   FEEDING. 

tion  with  lukewarm  water,  rapid  drying,  wrapping  in  a 
blanket,  and  rest. 

Mustard  pack  is  somewhat  less  efficient  than  mustard 
bath,  but  it  is  also  less  severe  and  less  disturbing  to  the 
infant.  The  naked  child  is  wrapped  in  a  blanket  which 
has  been  wrung  out  of  water  prepared  as  above  stated. 
The  infant  is  left  in  the  pack  until  the  skin  is  well  red- 
dened— about  ten  to  twenty  minutes — then  washed  off 
with  warm  water,  followed  by  lukewarm  water  ablution, 
dried,  and  put  to  bed  without  dressing. 

STOMACH  WASHING. 

The  apparatus  for  stomach  washing  consists  of  a  soft 
rubber  catheter,  20  to  24  French,  or  infant  stomach-tube, 
a  small  funnel,  attached  to  a  rubber  tube,  and  a  glass 
connection  between  the  catheter  and  the  tube. 

The  infant  is  wrapped  with  the  arms  confined,  and  is 
held  in  the  sitting  position,  wath  a  large  basin  at  the 
nurse's  feet.  The  tongue  is  depressed  with  the  forefinger 
of  the  left  hand,  and  the  right  hand  passes  a  catheter 
rapidly  backwards  into  the  pharynx  and  down  into  the 
oesophagus.  Gagging  is  aggravated  by  passing  this 
catheter  slowly.  After  the  catheter  is  part  way  in  the 
oesophagus,  it  should  be  passed  more  slowly.  As  the 
cardiac  orifice  is  passed,  and  the  catheter  enters  the  stom- 
ach, gagging  again  becomes  more  evident.  This  can  be 
used  as  a  sign  that  the  catheter  is  entering  the  stomach. 
A  good  rule  to  follow  in  passage  of  the  catheter  is  to 
measure  the  distance  from  the  root  of  the  nose  to  the 
tip  of  the  ensiform  cartilage,  which  approximates  the 
distance  from  the  teeth  to  the  cardiac  end  of  the  stom- 
ach, and  then  pass  the  catheter  about  an  inch  farther. 
The  passage  into  the  stomach  is  usually  marked  by  the 


APPENDIX.  305 

appearance  of  curdled  milk  in  the  glass  connecting  tube. 
The  funnel  should  now  be  raised  as  high  as  possible,  to 
facilitate  the  escape  of  any  gases  from  the  stomach,  and 
should  then  be  lowered,  in  order  to  siphon  any  fluid  con- 
tents. The  funnel  is  then  raised,  and  warm  water  at  a 
temperature  of  about  100°  F.  is  poured  into  the  stomach, 
quickly.  The  amount  of  water  passed  into  the  stomach 
at  any  time  should  about  equal  the  quantity  of  the  feed- 
ing to  which  the  child  is  accustomed.  The  funnel  is  then 
lowered,  just  before  all  of  the  water  leaves  the  tube,  and 
the  water  siphoned  out.  This  procedure  is  repeated  a 
number  of  times,  until  the  fluid  comes  back  clear.  Dur- 
ing withdrawal,  the  tube  must  be  compressed  carefully  to 
prevent  leakage  into  the  larynx.  The  washings  should 
be  collected  and  measured,  so  that  the  quantity  remaining 
in  the  stomach  may  be  estimated. 

Sterile  water  or  one-half  strength  normal  saline, 
Ringer's  solution,  or  a  solution  containing  sodium  chlo- 
ride 5  Gm.,  sodium  bicarbonate  5  Gm.,  and  water  100 
mils,  may  be  used.  It  is  frequently  advisable  to  allow 
part  of  the  solution  to  remain  in  the  stomach. 

Stomach  washing  is  indicated  in  vomiting  due  to  pylo- 
rospasm,  hypertrophic  pyloric  stenosis,  all  forms  of  gas- 
tric irritation,  chronic  indigestion,  acute  dilatation  of  the 
stomach,  and  food  and  drug  poisoning. 

CATHETER    FEEDING    BY    MOUTH. 

The  same  apparatus  is  used  as  in  stomach  washing, 
the  same  technic  being  used  for  the  introduction  of  the 
catheter,  except  that  its  tip  should  not  be  made  to  pass 
the  cardiac  end  of  the  stomach,  the  food  being  allowed 
to  enter  the  oesophagus  just  above  the  cardia.  This  is 
accomplished  by  passing  the  catheter  about  one-half  inch 

20 


306  INFANT   FEEDING. 

less  than  the  distance  from  the  root  of  the  nose  to  the 
tip  of  the  ensiform  cartilage.  The  infant  should  be  lying 
on  its  back,  and  not  in  sitting  posture,  as  recommended 
in  stomach  washing.  When  the  feeding  is  finished,  the 
catheter  should  be  tightly  pinched  between  fingers  and 
rapidly  withdrawn,  to  prevent  any  food  from  trickling 
into  the  larynx.  It  is  often  advisable  to  wash  the  stom- 
ach before  the  food  is  introduced. 

Catheter  feeding  is  indicated  in  the  feeding  of  pre- 
mature infants,  infants  refusing  their  diet,  those  too 
weak  to  nurse,  in  the  presence  of  persistent  vomiting,  and 
in  all  cases  of  delirium  and  coma. 

CATHETER    FEEDING    BY    NOSE. 

This  is  not  indicated  in  young  infants.  In  older  chil- 
dren it  is  often  impossible  to  pass  the  catheter  through 
the  mouth,  without  undue  struggling.  It  is  also  indicated 
in  throat  paralysis  following  poliomyelitis  and  diphtheria, 
and  after  throat  operations  and  intubation.  The  method 
is  similar  to  that  described  in  catheter  feeding  by  mouth, 
except  that  a  smaller  catheter  (No.  15  French)  is  to 
be  used. 

IRRIGATION    OF    THE    COLON    AND 
RECTAL    FEEDING. 

The  apparatus  varies  somewhat  with  the  purpose  to  be 
accomplished.  Where  large  quantities  of  fluids  are  to 
be  introduced,  it  is  necessary  to  use  a  douche-can  or 
fountain  syringe,  4  to  5  feet  of  tubing,  and  a  flexible 
rectal  tube  or  soft  rubber  catheter  (size  20  to  24  French). 
When  small  quantities  are  to  be  introduced,  a  glass  fun- 
nel may  be  used  in  place  of  the  douche-can.  When  large 
quantities  of  fluid  are  used,  the  can  must  not  be  raised 


APPENDIX.  307 

more  than  2  feet  above  the  child's  body.  The  child 
should  be  turned  upon  its  side,  with  the  lower  limb  ex- 
tended, and  the  upper  thigh  flexed  upon  the  abdomen. 
The  catheter  should  be  well  oiled,  and  introduced  for 
about  3  to  4  inches  when  large  quantities  are  to  be  given, 
and  further  introduction  of  the  catheter  may  be  made 
while  the  solution  is  flowing  into  the  rectum. 

Indications.  1.  To  produce  evacuation  of  the  bowel. 
A  salt  solution  containing  a  level  teaspoonful  of  salt  to 
a  pint  of  tepid  water  or  weak  soap-suds  solution,  or  a 
teaspoonful  of  glycerin  in  an  ounce  of  water;  or  in  the 
presence  of  large  fecal  masses,  2  or  3  ounces  of  sweet 
oil  may  be  used. 

2.  To  reduce  temperature.  At  least  1  to  4  quarts  of  a 
salt  solution  or  weak  soap-suds  enema  at  about  95°  F. 
should  be  used,  allowing  about  ^  to  1  pint  to  enter  the 
rectum,  and  repeating  after  expulsion. 

3.  Rectal  feeding.  A  normal  salt  solution  or  nutrient 
enemata  containing  2  level  tablespoonfuls  of  dextrose  to 
the  pint  of  normal  saline  solution  may  be  used.  It  is 
indicated  in  cases  of  acidosis,  and  also  in  the  presence  of 
vomiting,  intoxication,  and  decomposition  where  the  body 
is  in  need  of  water.  It  is  usually  necessary  that  only  a 
small  amount  (2  to  6  oz.)  of  this  solution  be  introduced 
at  a  time,  or  that  it  be  given  by  the  drop  method.  Other- 
wise it  will  not  be  retained.  It  should  be  repeate'd  at 
regular  intervals  of  from  two  to  four  hours.  It  may  be 
necessary  to  compress  the  buttocks  for  twenty  minutes 
after  administration,  when  the  fluid  is  not  well  retained 
otherwise. 

4.  Medication.  There  are  two  indications  for  rectal 
medication :  ( 1 )  For  the  systemic  effect.  The  drugs 
most  commonly  used  for  this  purpose  are  chloral  hydrate 


308  INFANT   FEEDING. 

and  the  bromides,  more  especially  in  the  presence  of 
convulsions  or  coma.  They  should  be  diluted  in  small 
quantities  of  water  or  salt  solution,  not  over  1  ounce,  and 
ma}'  be  administered  in  about  four  times  the  oral  dose 
for  the  given  age.  (2)  For  local  effect.  Enemata 
are  indicated  for  their  local  eft"ect  in  the  presence  of 
marked  tenesmus,  inflammation,  ulceration  and  hemor- 
rhage. Not  infrequently  the  tincture  of  opium  (3  to  5 
drops)  and  tincture  of  belladonna  (3  to  5  drops)  are 
administered,  probably  best  in  a  10  per  cent,  starch  solu- 
tion, for  their  sedative  eft'ect.  In  the  presence  of  in- 
flammatory processes,  1  per  cent,  silver  nitrate  solution 
may  be  used. 

SALINE    SOLUTIONS. 

1.  For  subcutaneous  use.  They  are  especially  indi- 
cated in  the  presence  of  considerable  loss  of  body  fluids 
through  vomiting,  refusal  of  diet,  and  diarrhea,  and  in 
the  presence  of  acidosis.  Rectal  administration  should 
first  be  tried,  and,  in  case  that  suflicient  fluids  cannot  be 
administered  to  meet  the  infant's  needs  in  this  way,  hypo- 
dermoclysis  should  be  instituted.  In  infants  2  to  4 
ounces  can  usually  be  administered,  and  in  older  children 
4  to  6  ounces.  This  can  be  repeated  every  four  hours, 
if  necessary,  or  until  fluids  can  be  supplied  by  another 
route.  Fluids  can  be  administered  beneath  the  skin  of 
the  abdomen,  chest,  or  lumbar  region.  There  is  some 
shock  accompanying  the  administration  of  large  quanti- 
ties of  fluids  subcutaneously,  probably  due  to  the  pain, 
and  it  is  frequently  necessary  to  give  a  child  in  collapse 
some  subcutaneous  stimulation  of  camphor  in  oil  (10  per 
cent.  1  mil),  or  adrenalin  solution  (1:1000,  about  5 
drops),  before  administration.    The  stimulating  injection 


APPENDIX.  309 

is  to  be  made  in  regions  of  the  body  other  than  where  the 
saHne  injection  is  made. 

The  best  solutions  for  this  purpose  are 

(a)  NaCl    7.5  grams. 

KCl    0.1 

CaCl    0.2 

Water,  q.  s.  ad  1000.0  mils. 

(b)  Dextrose  may  be  added  to  the  above  solution  in 

proportion  of  50  grams  to  the  liter  (5  per  cent.). 

All  solutions  used  for  subcutaneous  administration 
should,  if  possible,  be  made  from  fresh  distilled  water, 
and  re-sterilized  shortly  before  use. 

2.  Intravenous  injections.  The  same  solutions  as  in- 
dicated for  subcutaneous  use  may  be  administered  intra- 
venously. Sodium  bicarbonate,  30  Gm.  to  the  Hter,  being 
added  in  the  presence  of  acidosis  and  dextrose,  50  Gm. 
to  the  liter  in  cases  of  malnutrition  and  decomposition. 
Either  direct  or  indirect  transfusions  of  blood  are  also 
of  extreme  value  in  the  presence  of  marked  marasmus. 

Technic.  In  older  infants  and  children  the  injection 
may  be  made  into  the  external  jugular  or  median  basilic 
or  median  cephalic  veins.  In  young  infants  with  open 
fontanelle,  the  longitudinal  sinus  is  the  most  convenient 
point  for  administration.  However,  in  the  use  of  the 
latter  method  extreme  care  must  be  used,  because  of  the 
ease  with  which  the  sinus  wall  can  be  punctured.  All 
apparatus  used  in  the  intravenous  administration  must 
be  thoroughly  and  freshly  sterilized  before  use.  Where 
a  moderate  quantity  of  fluid  is  to  be  administered  (2  mils, 
10  mils,  or  20  mils)  all  glass  Record  or  Luer  syringes  can 
be  used.  In  injection  of  fluids  into  the  longitudinal  sinus 
a  short  bevelled  needle,  about  0.75  inch  in  length,  should 
be  introduced  at  the  posterior  angle  of  the  fontanelle. 


310  INFANT   FEEDING. 

The  region  of  the  fontanelle  is  sterihzed,  and  the  first 
syringe  is  three-quarters  filled  with  the  fluid  to  be  in- 
jected. The  syringe  is  now  connected  with  a  needle  by 
means  of  a  short  piece  of  rubber  tubing  to  allow  flexibil- 
ity in  case  of  movements  on  the  part  of  the  child,  and  the 
needle  is  passed  into  the  sinus,  its  entrance  being  recog- 
nized by  a  sudden  lessening  of  the  resistance.  Helmholz* 
suggests  that  the  question  of  negative  pressure  within  the 
sinus  is  one  that  must  not  be  overlooked*  and  it  is  always 
well  in  entering  the  sinus  to  have  the  syringe  attached, 
and  before  injection  to  withdraw  blood,  to  make  sure  that 
the  needle  is  in  the  sinus.  Unless  a  head-clamp,  as 
described  by  Helmholz  is  available,  two  assistants  are 
required,  one  to  hold  the  child's  head  firmly,  and  the 
second  to  manage  the  syringe,  while  the  physician  steadies 
the  needle.  From  100  to  200  mils  of  either  a  saline,  dex- 
trose solution  or  citrated  or  fresh  blood  can  usually  be 
administered  without  difficulty.  Ungerf  has  described  an 
apparatus  whereby  large  quantities  of  fresh  blood  can  be 
transfused. 

HOME-MADE  ICE-BOX. 

The  following  home-made  ice-box  described  by  Holt 
and  Shaw  will  answer,  if  a  more  elaborate  refrigerator  is 
not  available. 

Get  from  your  grocer  a  deep  box  about  18  inches 
square,  and  put  3  inches  of  sawdust  in  the  bottom.  Place 
two  pails  in  this  box — one  a  smaller  pail,  inside  the  other 


*  Helmholz.  H.  F. :  The  longitudinal  sinus  as  the  place  of 
preference  in  infanc}-  for  intravenous  aspirations  and  injections, 
including  transfusion.     Am.  Jour.  Dis.  Child.,  1915,  x,  194. 

t  Unger,  J.  J. :  A  new  method  of  syringe  transfusion.  Jour. 
Am.  Med.  Ass'n.,  1915,  Ixiv,  582. 


APPENDIX. 


311 


— and  fill  the  space  between  the  outer  pail  and  the  box 
with  sawdust.  The  nursing  bottles  filled  with  milk  are 
placed  in  the  inner  pail.  This  pail  is  then  filled  with 
cracked  ice,  which  surrounds  the  bottles.  The  inner  pail 
should  have  a  tin  cover.  Nail  several  thicknesses  of 
newspaper  on  the  Imder  surface  of  the  cover  of  the  box. 
This  ice-box  should  be  kept  covered,  and  in  a  shady,  cool 
place.  The  water  from  melted  ice  should  be  poured  off, 
and  the  ice  renewed  at  least  once  each  day. 


Fig.  20. — An  asbestos-lined  copper  receptacle  for  electric 
heating  pads  for  use  in  the  care  of  premature  and  debili- 
tated infants  (Hess).  To  avoid  the  danger  of  fire  from 
short  circuits  in  electric  heating  pads,  a  copper  receptacle 
is  used,. 16  inches  long,  13  inches  wide,  and  V/i  inches  high, 
into  which  a  12  x  15-inch  heating  pad  is  laid.  To  allow  of 
a  maximum  radiation  from  the  lid  or  upper  surface  of  the 
same,  the  floor  and  sides  are  lined  with  asbestos  sheeting, 
while  the  lid  is  not  lined.  The  cord  passes  through  a  small 
rubber  insulator  at  the  side  to  prevent  contact  with  the 
metal  and  injury  to  the  cord.  This  simple  device  can  be 
used  temporarily  in  wards  and  homes  where  better  facili- 
ties for  the  care  of  this  class  of  infants  are  lacking.  It  is 
to  be  placed  in  the  bottom  of  a  basket  or  crib,  under  the 
mattress  or  pillow. 


312  INFANT   FEEDING. 

CASE    HISTORY. 

(A)  Present  Illness. 

1.  Complaints:    Mother's  or  patient's  own  statement. 

2.  Get  history  of  present  illness  in  detail :  onset,  course 

and  duration.    Fever.    Vomiting.    Stools.    Urine. 
Eruptions.    Sleep,  etc. 

3.  Previous  treatment,  if  any. 

(B)  Previous  History. 

1.  Birth:   Para,  nature  and  complications. 

2.  Development:    Teeth  (time  of  eruption),  sat  erect, 

walked,  talked,  mentality. 

3.  General  Health :   Robust  or  delicate,  appetite,  colds, 

fevers,     coughs,     bowels,     convulsions,     mouth- 
breathing,  running  ears,  bed-wetting,  etc. 

4.  Illnesses:    Diseases  similar  to  the  present.     Kind, 

date,    duration,    severity,    recurrences,    complica- 
tions, careful  history  of  acute  infectious  diseases. 

5.  Feeding:   In  detail  in  every  infant. 

(a)  Breast  feeding:   How  long,  intervals,  condition 

of  the  baby,  why  discontinued. 

(b)  Artificial  feeding:   Kind  of  food,  intervals,  how 

prepared,  how  much  at  each  feeding,  total 
quantity,  how  long  used,  effect  on  baby  and 
on  bowels,  why  discontinued. 

(C)  Family  History. 
Parents,  brothers  and  sisters. 

(Constitutional  diseases:  Tuberculosis,  syphilis,  mis- 
carriages (order  of),  rheumatism,  nervousness  or  insan- 
ity, alcoholism). 

(D)  Examination.  , 
Examine  patient  fully. 


APPENDIX.  313 

1.  General  appearance  and  zveight:   Nutrition  and  gen- 

eral development,  facial  expression  (intelligence, 
pain,  etc.),  amount  of  prostration,  pallor,  cry, 
nervous  condition,  posture,   respiration. 

2.  Skin :   Eruptions,  turgor. 

3.  Temperature:     Pulse    and    respiration    (in    infant 

omit  temperature  until  11). 

4.  Head:     Size,    shape,    fontanelles     (size,    tension), 

cranio-tabes,  eyes,  nose  (mouth,  tongue,  teeth 
under  12). 

5.  Neck:  .Goiter,  glands,  rigidity. 

6.  Chest:   Shape,  deformities,  inequalities,  expansions, 

kings  and  heart  in  detail. 

7.  Abdomen:    Size,  distention,  retraction,  tenderness, 

rigidity,  liver,  spleen,  bladder,  kidney,  fluid  and 
tumors. 

8.  Spine :  Deformities,  rigidity. 

9.  Genitalia  and  genital  region :  Phimosis,  vaginal  dis- 

charge, fissures,  inflammation,  eruptions,  hemor- 
rhoids, pin-v^orms,  etc. 

10.  Extremities:     Glands,    deformities,    paralyses,    at- 

rophy,   muscle    tone,    reflexes,    athetosis,    swell- 
ing, tenderness,  discoloration,  joints,  gait. 

11.  Temperature  :   In  child  under  3  years  always  rectal, 

and  often  in  older  children. 

12.  Mouth:     Teeth,    tongue,    stomatitis,    enanthemata, 

pharynx,  tonsils,  adenoids. 

13.  Middle  ear. 

14.  Special  examinations:    Urine,  blood,  sputum,  cul- 

tures, feces,  vaccinations,  serum  reactions,  etc. 


314 


IXFAXT    FEEDING. 


AVERAGE    WEIGHTS. 


Girls 
Pounds 


Boys 
Age  Pounds 

Birth  7.55 7.16 

Six  months 16.50 15.50 

Twelve  months   20.50 19.80 

Eighteen  months  22.80 22.00 


Two  years 26.50. 

Three  years  31.20. 

Four  years    35.00. 

Five  3-ears  41.20. 

Six  5'ears   45.10. 

Seven  years    49.50. 

Eight  years    54.50. 

Nine  years    60.00. 

Ten  years    66.60. 

Eleven  years   72.40. 

79.80. 

88.30. 


25.50 

30.00 

34.00 

39.80 

43.80 

48.00 

52.90 

57.50 

64.10 

70.30 

81.40 

91.20 

99.30 100.30 


Twelve  years    

Thirteen  3'ears    

Fourteen  years    

Fifteen  vears   110.80 108.40 


Sixteen  vears 


123.70 113.00 


MEASUREMENTS. 

Age                          Height  Chest 

in.  in. 

Birth    20.5  .           13.25 

6  months    25.0  16.0 

1  year    29.0  18.0 

2  years    32.5  19.0 

5  vears    41.5  21.0 


Head 
in. 

13.75 

17.0 

18.0 

18.75 

20.5 


Head  at  birth.  13.75  inches.  First  year,  gain  4  inches; 
second  year,  gain  1  inch;  2  to  5  years,  gain  1.5  inches  for 
the  3  years. 

Large  head  and  small  chest  suggests  rickets.  The  head 
is  larger  than  the  chest  until  second  year,  normally. 


APPENDIX.  315 

GENERAL    DEVELOPMENT. 

A  healthy  infant  speaks  single  words  toward  the  end 
of  the  hrst  year,  uses  short  sentences  at  the  end  of  the 
second  year;  sits  erect  at  the  seventh  month;  stands  with 
assistance  at  ninth  or  tenth  month;  attempts  to  walk  at 
twelfth  or  thirteenth  month,  and  walks  freely  at  the' 
fourteenth  or  fifteenth  month. 

SLEEP. 

The  healthy  infant  sleeps  practically  all  the  time  ex- 
cept when  being  fed. 

Hours 
per  day 
At  birth   20  to  22 

At  end  of  1st  year 16  "  1.8 

During  2d  and  3d  years   12  "  13 

During  4th  and  5th  years  10  "  11 

During  12th  and  13th  years    '. 8  "  9 

ORDER    AND    AVERAGE    TIME    OF    ERUPTION 
OF    THE    TWENTY    DECIDUOUS    TEETH. 

Months 
2  lower  central  incisors   6  to     9 

4  upper    incisors    8   "    12 

2  lower     lateral     incisors    and     4    anterior 

molars    12   "    15 

4  canines    18   ''    24 

4  posterior  molars    24   "    30 

At  1  year  should  have  6  teeth. 

At  1  year  6  months  should  have  12  teeth. 

At  2  years  should  have  16  teeth. 

At  2  years  and  6  months  should  have  20  teeth. 


316  INFANT    FEEDING. 

PERMANENT    TEETH. 

Years 
1st  molars   . .  • 6 

Incisors    7  to  8 

Bicuspids   9   "  10 

Canines    12  "  14 

Second  molars   12   "  15 

Third  molars    17   "  25 

CLOSURE    OF    FONTANELS. 

Posterior  fontanel  usually  closes  b}^  the  end  of  the 
second  month.  Anterior  fontanel  at  the  end  of  the  first 
year  is  about  1  inch  in  diameter,  and  usually  closes  at  the 
eighteenth  month.  Normal  variations,  from  fourteen  to 
twenty-two  months. 

AVERAGE  DAILY  QUANTITY  OF  URINE 
IN  HEALTH. 

Ounces 

1st  24  hours  0  to    2 

2d  24  hours %   "      3 

3  to  6  days   3   "     8 

7  days  to  2  months 5   "'    13 

2  to  6  months 7   "    16 

6  months  to  2  years 8   "    20 

2  to  5  years  .  . ' 16   "    26 

-     5  to  8  years   20   "   40 

8  to  18  years Z2   "   48 

AVERAGE    RATE    OF    PULSE    AND 
RESPIRATION. 

Pulse  Respirations 

Birth   140  35  to  40 

1  month   ...120  25   "   40 

6  to  12  months  105  to  115      25  "  30 

2  to  6  years  90  "  105       25 

7  to  10  years  80  "  90      22  "  25 

11  to  14  years 75  "  80      20 


APPENDIX.  317 

BLOOD-PICTURE    IN    HEALTHY    CHILDREN. 

Newborn  Infants  Older  children 

HcTmoglobin    110  percent.        70  to  95  per  cent.     65  to  95  per  cent. 
Erythrocytes   5  to  8  millions    4.5  to  5.5  millions    4  to  4.5  millions. 

AVERAGE  WHITE  CELL  COUNTS. 

1.  Healthy  children  between  1  and  15  years  of  age 
average  between  7000  and  15,000  leucocytes,  approxi- 
mately the  same  as  adults. 

2.  Polymorphonuclear  neutrophiles  increase  gradually 
from  30  per  cent,  in  the  first  year  to  about  70  per  cent, 
in  the  fifteenth  year. 

3.  Lymphocytes  decrease  from  60  per  cent,  in  the  first 
year  to  about  30  per  cent,  in  the  fifteenth  year.  (This 
represents  combined  (large  and  small)  lymphocytes). 

4.  The  reversal  of  the  percentages  of  neutrophiles  and 
lymphocytes  occurs  usually  about  the  sixth  year. 

5.  Eosinophiles  average  between  4  to  6  per  cent.,  but 
vary  greatly  in  different  children  at  the  same  ages. 

6.  Transitional  cells  average  approximately  2  to  3  per 
cent.,  not  varying  greatly  at  the  different  ages. 

7.  Mast-cells,  about  0.3  to  0.6  per  cent.  Frequently 
absent. 

8.  Large  mononuclear  neutrophiles,  1  to  3.3  per  cent. 
About  the  same  at  different  ages. 

stool  symbols  Urine  symbols 

N  =  normal.  A  ^albumin. 

S  =  soft.  S  =  sugar. 

W  =  watery.  Ac  =  acetone. 

F  =  fat-soap.  D  =  diazo. 

M  =  mucus.  I  =  indican. 

Bl  =  blood.  C=:  casts. 

C  =  curds.  P  =  pus. 

G  =  green.  Bl  =  blood. 

Ep  =  epithelium. 


318  INFANT   FEEDING. 

RECORD    SHEET. 

A  brief  description  of  the  clinical  sheet  used  in  our 
wards  mav  be  of  value,  as  it  answers  both  the  needs 
of  a  histor}^  sheet  and  of  a  daily  chart  as  well.  The 
points  illustrated  by  it  are :  a  graphic  relationship 
between  the  temperature,  weight,  quality,  and  quan- 
tity of  food  taken,  and  the  end-results  on  the  stools 
and  urine.  Also  separate  spaces  are  provided  for 
complications  which  may  influence  the  preceding 
under  the  heading-  of  symptoms,  together  with  spaces 
for  treatment  other  than  dietetic,  energy  value  of 
foods,  vomiting,  blood  examinations,  tuberculin  re- 
actions, etc.  The  small  figures  1-10  are  used  to  make 
an  electrical  reaction  curve  in  cases  showing  a  spas- 
mophilic diathesis. 


APPENDIX. 


319 


SARAH  MORRIS  HOSPITAL 

FOR 

CHILDREN 

o 
a 

i 

auou 

•3'  a 

9 

it 

o 
o 

C/3     O 

d  o 
§  o 

o 

P       P       ?       ?       F       ? 

1     ;     1     1      1     1     1     1     1     'i     1     1     1 

*1 

9  ? 

p         O         0         0         O          0         0         O         0         0         0         0         0         c 

i 

f 

SWIPTOMS 

MtDlCATION 

f 

- 

> 

a.    B 
&>     5 

- 

j 

t 

z 

l 

d 

I 

z 

2 

?• 

2 

:r    o 

=■ 

2 

a 

2 

^ 

2 

2 

?■ 

PI 

S 

> 

?~fT 

~o 

^ 

1 

•• 

^ 

.* 

- 

n 

> 

PI 

??? 

c 

T 

i 
1 

^ 

J 

._ 

J 

= 

"= 

320 


INFANT   FEEDING. 


DEPARTMENT    OF     PEDIATRICS 

UNIVERSITY    OF    ILLINOIS  —      COLLEGE    OF    MEDICINE 


e 

Z 

Address 

Date 

Sex 

Aae 

Race 

Diagnosis 

• 

a 
Z 

Doctor 

History  of  Patient. 

Duration,    progress,    onset,    eariiest  symptoms   and   later   developments 


Previous  History. 
BIRTH:     Para?     Natare  and  Complications- 


DEVELOPMENT:     Teeth 


Mentality 


GENERAL  HEALTH: 


APPENDIX. 


321 


PREVIOUS    ILLNESSES 


FEEDING   HISTORY 


No.  of  Months 


Why   di^TOniinueg 


ARTIFICIAL  FEEDING.  In   Detail 


FAMILY  HISTORY 


PHYSICAL  EXAMINATION 


21 


322 


INFANT   FEEDING. 


TEMPERATURE                         P 

R 

Weight 

Height 

1 

LABORATORY  EXAMINATIONS                                                                                                                                                                                   I 

f 

TREATMENT 

ASSIGNED    TO 

APPENDIX. 


323 


SUBSEQUENT    TREATMENT    AND     REMARKS 

1 

Date 

Weight 

' 

1 

INDEX. 


Abdomen,    distended    in    over- 
feeding on  the  breast,  79 
Acetone  bodies,  15 
Acid,  aceto-acetic,  15 
amino,  9,  30 
fatty,  178 
fatty  in  stools,  12 
hydrochloric^  fmiction,  5 
in  stomach,  4 
lactic,  32 

oxy butyric  in  urine,  10,  15 
uric,  10 
Acidity  of  the  stomach,  4 
Acidosis,  decomposition,  209 
disturbed   metabolic   balance, 

189 
intoxication,  226,  227 
overfeeding  on  the  breast,  80 
Age  of  nursing  mother,  36 
Albumin    milk,    caloric    value, 
150 
decomposition,  218 
recipe,  292,  293 
v^ater,  281 

with  beef  extract,  281 
Albumins,  in  milk,  8 

in  urine,  24 
Albumoses,  9 

Alcoholism,    hereditary    weak- 
ness, 84 
Alexins  in  milk,  36 
Alkali  soaps  in  stools,  12 
Allaitement  mixte,  67 
Allenberry's  I,  II,  274 

III,  275 
American  Association  of  Medi- 
cal Milk  Commissioners, 
115 
American  school  of  pediatrics, 

107 
Ammonia  coefficient,  11 
in  urine,  10 


Amylopsin,  5 

Anemia,  boiled  milk,  120 

Anglo-Swiss,  274 

Anions,  16 

Anorexia,     enteral     infections, 

260 
Antitoxins  in  milk,  36 
Anuria,  24 

Apnea  in  decomposition,  215 
Appetite  lessened,   overfeeding 

on  the  breast,  78 
Apple  sauce,  caloric  value,  156 

recipe,  291 
Arrowroot,  274 
Artificial  feeding,  107 
adaptation  of  milk,   124 
amount  at  each  feeding,  152 
caloric  contents,  146 
caloric  method,  108 
carbohydrates,  140,  153 
cereal  flours,  142 
cow's  milk,  110 
curd  breaking,  154 
dextrin     and     maltose     com- 
pounds, 142,  154 
energy  quotient,  149 
example  No.  1,  157 
example  No.  2,  158 
fats,   138 

first  weeks  of  life,  159 
milk   dilutions  with   addition 

of  carbohydrates,   129 
mixed    diet    for    young    in- 
fants, 155 
number  of  feedings  in  a  dav, 

152 
nutritional    disturbances,    see 
Nutritional   Disturbances 
in    Artificially    Fed    In- 
fants, 
objects  to  be  attained,  130 
percentage  method,  126 

(325) 


326 


INDEX. 


Artificial  feeding,  proteins,  134 

salts,  143 

starch,  153 

sugars,  141 
quantity,  154 

summary,  161 

top  milkj  127 

undiluted  whole  milk,  126 

water,  145,  152 
Asparagus,  289 

Assimilation   capacity   for   car- 
bohydrates, 14,  140 
Atresias  of  the  intestinal  tract, 

85 
Atrophy,  207 

moderate  degree,  186 
Autointoxication,  31 

Bacillus  acidophilus,  25,  27,  28, 
30 

aerogenes  capsulatus,  27,  255 

bifidus,  25,  26,  27,  29 

coli,  25,  28,  255 

dysenterise,  31,  255 

lactis  aerogenes,  25,  29,  255 

mesentericus,  27 

paratyphosus,  255 

pyocyaneus,  255 

typhosus,  255 
Bacon,  caloric  value,  156 
Bacteria    of    the    gastro-intes- 
tinal    tract    of    the    arti- 
ficially fed  infant,  27 

diet  influencing,  29 

gastro-intestinal  disturbances, 
31 

newborn  infant,  25 

nursing  infant,  25 

proteolytic,  29 

causing  disease,  33 

saccharolytic,  29 

significance,  28 
Barley,  dextrinization,  280 

jelly,  280 

water,  280  .  _ 

Basedow's    disease,    contraindi- 
cation to  nursing,  38 
Bath,  bran,  300 

cold,  302 


Bath,  daily,  300 

hot,  303 

mustard,  303 

room,  hospital,  301 
Beans,  290 
Beef  juice,  288 
Biedert,  111,  177 
Bier  pump,  76 
Bile,  functions,  6 
Blood  in  healthy  children,  317 
Borcherdt's  dri  malt  soup,  142 
extract,  275 

with  wheat  flour,  275 
laxative,  153 

malt  soup  extract,  275 
sugar,  275 
Bosworth,  154 
Bottles,  nursing,  295 
Brady,  148 

buttermilk    mixture    No.     1, 
284 
No.  2,  285 
Bread,  caloric  value,  156 

permitted  at  three  years,  167 
Breast,  Bier  pump,  76 

care  during  weaning,  69 

care  in  nursing,  42 

massage,  75 

pump,  60 

steaming,  76 

stimulation,  74 
Breck  feeder,  93 
Brennemann,  119,  126 
Bronchitis  in  breast-fed  infant, 

86 
Bronchoenterocatarrh,  255 
Broths,  recipes,  287 
Budin,  126 

Butter,  caloric  value,  156 
Buttermilk  and  skim  milk  mix- 
ture, 284 

caloric  value,  149 

mixture,  Brady's  No.  1,  284 
No.  2,  285 

caloric  value,  149 

recipe,  282,  283 

Calcium,  excretion  in  stools,  17 
metabolism,  145 


INDEX. 


327 


Calcium,  milk,  16 
paracasein,  17 
phosphate  in  milk,  17 
salts  and  water  retention,  18 
fat-soap  stools,  188 
phagocytosis  increased,   18 
putrefaction  favored,  30 
Caloric   contents    of   the    food, 
146 
intake  in  disturbed  metabolic 

balance,  190 
method    of    artificial    infant 

feeding,  108 
needs  of  infants,  147 
values  of  foods,  149,  156 
Camerer,  137 
Carbohydrates,  13 
artificial  feeding,  153 
bacteria  influenced,  33 
chemistry,  13 
colic  and  flatulence,  169 
disturbed   metabolic   balance, 

188 
fat  formation,  140 

relation,  15 
fermentation,  32 
fermentative  organisms,  29 
functions,  14,  140 
insufficient,   disturbed  metab- 
olic balance,  190 
metabolism,  13 
nitrogen  metabolism,  11 
quantities    in    artificial    feed- 
ing, 142,  161 
replacing  proteins    and    fats, 

15 
stomach  digestion,  20 
stools,  22 
tissues,  14 
tolerance  limited,  34 

high  in  infants,  140 
weight  increase,  15 
Carrots,  caloric  value,  156 

recipe,  289 
Case  historv,  312 
Casein,  chemistry,  9     , 
curds,  201 
metabolism,  9 


Casein,  powdered,  in  colic  and 
flatulence,  169 
in      overfeeding      on      the 
breast,  83 
salt  excretion,  17 
varying  percentages,  107 
Catheter  feeding  by  mouth,  93 
technic,  305 
nose,  306 
"Cell  hunger,"  208 
Cereal,  caloric  value,  156 
flours,  142 

permitted  at  three  years,  167 
waters,  caloric  value,  150 
Chittenden,  136 
Chlorine  in  milk,  16 
Cholera  infantum,  223 
Cholesterin,  19 
in  stools,  12 
Chymogen,  276 
milk,  caloric  value,  150 
recipe,  282 
Cleft     palate,     congenital     de- 
bility, 85 
Cohnheim,  5 
Coit,  Dr.  Henry  L.,  115 
"Colds,"    parenteral    iafections, 

249 
Colic  and  flatulence,  169 
change  of  sugar,  141 
overfeeding  on  the  breast,  79 
Colitis,  membranous,  257 

ulcerative  follicular,  257 
Collapse,  intoxication,  223,  230 
Colon,  irrigation,  306 
Coma,  intoxication.  230 
Complemental  feeding,  67 
Congenital    debilitv,    with    re- 
sulting    impairment      of 
vital  functions,  84 
Constipation,  170 
boiled  milk,  119 
chronic,    disturbed    metabolic 

balance,   192 
dextrin     and     maltose    com- 
pounds, 142 
disturbed   metabolic   balance, 

186 
excessive  milk  diet,  24 


328 


INDEX. 


Constipation,  fat,  186 
nursing  woman,  40 
Convulsions,  intoxication,  230 
Cow  producing  milk  for  infant 

feeding.  113 
Cowie,  137 

Crackers,  caloric  value,  156 
Cream,  caloric  value,  149,  156 
Curds,  breaking,  154 
cow's  milk,  112 
delaying  food  in  stomach,  21 
digestion  in  stomach,  22 
fat,  in  stools,  172 
protein  in  stools,  172 

in  dyspepsia,  196 
vomiting,  169 
Custard,  caloric  value,  156 
Cyanosis,  decomposition,  213 
Cvstitis.    parenteral    infections, 

249 
Cystopvelitis,  enteral  infections, 

261 
Czerny,  108,  176,  177,  182,  186, 
187,    208,    209,   223,    231, 
240 

Day,  249,  255,  256 
Death  in  decomposition,  215 
Debility,    congenital,    with    re- 
sulting    impairment     of 
vital  functions,  84 
Decomposition,  207 
death,  215 
diagnosis,  214 

differential,   185 
disturbed   metabolic   balance, 

192 
etiology,  207 
pathogenesis,  208 
prognosis,  214 
proteins,  31,  33 
symptoms,  210 
S3monyms,  207 
treatment,  215 
Dennett,  148 
Denno's  baby  food,  275 
Development,  general,  315 
Dextrin      and     maltose      com- 
pounds, 142 


Dextrose,   B.   acidophilus    fav- 
ored, 30 
Kahlbaum's,  233 
Diabetes,     contraindication     to 

nursing,  38 
Diaper,  298 
Diarrhea,  196 
dyspepsia,   196 
enteral  infection,  258 
overfeeding  on  the  breast,  78 
summer,  223 
Diastase,  5 
milk,  36 
Diastatic  ferments,  276 
Diastoid  (Horlick's),  276 
Diathesis,  exudative,  184 

disturbed     metabolic     bal- 
ance, 192 
psychoneuropathic,  184 
Diazyme   (Fairchild's),  276 
Diet,  hunger,  203 
intoxication,  234 
intestinal  flora,  29 
nursing  mother,  39 
starvation,  203 
7  to  12  months,  164 
12  to  24  months,  165 
14  to  18  months,  165 
18  months  to  3  years,  166 
Disaccharides,  13 
Disturbed     metabolic     balance, 
186 
artificial  food  diet,  192 
complications,  192 
diagnosis,  190 

differential,  185 
etiolog}^,  186 
human  milk  diet,  192 
pathogenesis,  187 
prognosis,  192 
sequellse,   192 
S3^mptoms,  189 
synonyms,  186 
treatment,  192 
Domestic    measures,     carbohy- 
drate equivalents,  150 
Drugs     influencing    production 

of  milk,  43 
Dunn,  137,  148 


INDEX. 


329 


Dysentery,  257 
Dyspepsia,  196 

diagnosis,  201 
differential,  185 

disturbed   metabolic   balance, 
185 

etiology,  196 

overfeeding  on  the  breast,  79 

pathogenesis,  196 

prognosis,  202 

symptoms,  198 

synonyms,  196 

treatment,  202 

Earthy  alkali  soaps  in  stools,  12 
Eczema,     disturbed     metabolic 
balance,  190 

overfeeding  on  the  breast,  80 
Edema,  decomposition,  213 

flour  injury,  242 
Egg,  caloric  value,  156 

permitted  at  three  years,  167 

recipe,  291 

white  and  digested  gruel,  281 
Eiweiss  milk,  292 
Energy  quotient,  12,  149 
Enteritis,  catarrhal,  223 
Enterokinase,  5 
Epilepsy,     contraindication     to 

nursing,  38 
Erepsin,  5 

action    on    end    products    of 
pepsin  digestion,  9 
Escherich,  27,  113.  178 
Eskay's  food,  275 
Excretion  and  intake,  7 
Expression  of  milk,  61 

Fat,  Fats,  11 
bacteria  influenced,  30 
chemistry,   11 
carbohydrates,  11 
colic  and  flatulence,  169 
constipation,  186 
delaying  food  in  stomach,  21 
disposition,  11 

disturbed   metabolic   balance, 
188 


Fat,   excessive,   causing  vomit- 
ing, 169 
disturbed     metabolic     bal- 
ance, 190 

formation      from      carbohy- 
drates, 14,  140  . 

functions,   138 

intolerance,  139 

intoxication,  226 

metabolism,  11 

niilk,  112 

nitrogen  metabolism,  11 

overfeeding,  186 

phosphorus  excretion,  17 

quantity  in  artificial  feeding, 
139,  161 

requirements,  140 

resorption,  11 

salts  excretion,  17 

soap  stools,  139,  171,  173,  186 

stomach  digestion,  20 

stools,   12 

urine,   12 
Feces,  color,  23 

composition,  21 

reaction  in  artificially  fed  in- 
fants, 27 

tests  on  constituents,  22,  200 
Feeding,  artificial,  see  Artificial 
Feeding. 

complemental,  67 

increases,  149 

mixed,  67 

quantity  at  different  ages,  2 

rectal,  306 

supplemental,  67 

too  frequent,  colic  and  flatu- 
lence, 169 
Fermentation,  22,  29,  Z2 

excessive,  34 
dyspepsia,  197 

sodium    and   potassium    salts 
increasing,  30 
Ferments,   diastatic,  276 

milk,  Z6 

mouth,  4 

pancreas,  5 

small  intestine,   5 

stomach,  5 


330 


INDEX. 


Fever,  enteral  infections,  260 

intoxication,  228 
Finkelstein,   108,   176,   177,   178, 
182,    186,    207,    218,    225, 
226,  227,  292 
Flatulence  and  colic,  169 
Flour,  ball,  280 
barley,  274 
caloric  value,  150 
injury,  240 
diagnosis,  243 
etiology,  240 

pathogenesis     and     metab- 
olism, 240 
prognosis,  243 
prophylaxis,  243 
treatment,  243 
Flours,  274 

Fontanelles,  closure,  316 
Food  elements  necessary,  7 
injuries,  176 
intolerance,  177 

decomposition,  210 
tolerance  lessened,  180 
Foods,  avoided  at  three  vears, 
167 
given   with   caution   at   three 

years,  167 
permitted  at  three  vears,  167 
Frank,  269,  270 

Fruits  permitted  at  three  years, 
167 
recipes,  290 

Galactase  in  milk,  36 
Galactagogues,  76 
Gastric  juice,  4 
Gavage,  93 

apparatus,  94 
Gelatin,  caloric  value,  156 

food,  292 

orange,  290 
General  development,  315 
German    school    of    pediatrics, 

108 
Gerstley,  249,  256 
Glanders  in  cow,  113 
Globulin  in  milk,  8 
Glycocoll,  9 


Glycogen,  14 
Glycosuria,  14 

intoxication,  231 
Gram,  neeative  bacteria,  27 

positive  bacteria,  26 
Gruel,    digested    and   white    of 
egg,  281 

Hamburger,  4,  113,  177 
Heart  disease,  contraindication 

to  nursing,  38 
Heat    causing    nutritional    dis- 
turbances, 180 

intoxication,  224 
Heating  pad,  receptacle,  311 
Helmholtz,  213,  310 
Hereditarv  weakness,  84 
Heubner, '73,  108,  147 
Hirschprung's  disease,  85 
Holt,  223,  310 
Honor    brand    powdered    milk, 

273,  279 
Hoobler,  137 
Horlick's,  malt  food,  276 

malted  milk,  274 
constipating,  142,  153 
Howland,  145,  227 
Hunger,  cell,  208 

decomposition,  212 

internal,  208 

mineral,  209 
Hj'pertonia,  flour  injury,  242 

Ice-box,  home-made,  310 
Idiosvncrasv,    cow's    milk,    173, 
'  187 

mother's  milk,  87 
Immunity,  flour  injury,  242 
Immunizing  bodies  in  milk,  36 
Imperial  granum,  274 
Inanition,  qualitative,  240 

quantitative,  238 
Indigestion,  196 
Indol,  30 

Infant,  artificiallv  fed,  normal, 
130,  181      ^ 

breast-fed,     nutritional     dis- 
turbances, 71 


INDEX. 


331 


Infant  foods,  proprietary,  273 
infections,  85 
nursing,  64 

premature,  see  Premature  In- 
fant, 
underweight,  feeding,  151 
Infections,    breast-fed    infants, 
85 
enteral,  254 

complications,  260 
dyspepsia,   196 
diagnosis,  261 
etiology,  254 
pathology,  256 
prognosis,  264 
symptoms,  258 
treatment,  265 
intoxication,  223,  227 
nutrition,  245 
parenteral,  248 
diagnosis,  250 
dyspepsia,  191 
etiology,  248 
symptoms,  250 
treatment,  252 
susceptibility,    decomposition, 

213 
weaning,  68 
Intake  and  excretion,  7 
Intermediary   metabolism,   7 
Intertrigo,   disturbed  metabolic 

balance,  190 
Intestines,  anatomy,  2 
bacteria,  26 
functions,  21 
milk  digestion,  21 
physiology,  5 
Intolerance,  food,  177 
Intoxication,  223 
alimentary,  223 
definition,  223 
diagnosis,  232 

differential,  185 
disturbed   metabolic   balance, 

192 
etiology,  223 
gastro-enteric,  223 
overfeeding  on  the  breast,  80 
pathology,  22il 


Intoxication,  pathogenesis,  225 

prognosis,  232 

symptoms,  228 

treatment,  232 
Intravenous    saline    injections, 

309 
Invertin,  5 
Ions,  15 
Iron,  excretion  in  stools,  18 

milk,   16 
Irrigation  of  the  colon,  306 

Rations,  16 

Keller,  186,  216,  223,  231,  240 

Keller's     malt     soup,      caloric 
value,  150 
constipation,    171 
contraindications,  286 
disturbed    metabolic   balance, 

193 
indications,  286 
recipe,  286 

Kendall,  249,  255,  263 

Kreatinin  in  urine,  10 

Lacta  prseparata,  273 
Lactase,  5 

Lactokinase  in  milk,  Zd 
Lactometer,  36 

Lactose,    bacillus    bifidus    fav- 
ored, 29 

laxative  tendency,   153 

saccharose  compared,  141 
Larosan,  276 

milk,  294 
Lavage,  apparatus,  94 
Lecithin,  19 

in  stools,  12 
Leucocytosis,  intoxication,  231 
Lime  water  to  break  curds,  155 
Lipase,  5 

in  milk,  36 
Lipoids,  19 
Liver,  anatomy  of,  3 

enlaro-ement,  intoxication,  231 
physiology  of,  5 
Longitudinal    sinus,    injections, 
310 


2>2,2 


INDEX. 


Magnesium  excretion  in  stools, 
17 
in  milk,  16 

salts,  fat-soap  stools,  188 
Malformations      of.      digestive 
tract    causing    congenital 
debility,  85 
Mallein  test  in  cows,  113 
Malnutrition,  186 
Malt     soup,     extract,      caloric 
value,  150,  156 
Keller's,  caloric  value,   150 
Maltase,  5 

Maltose      and      dextrin      com- 
pounds, 142 
caloric  value,  150 
favoring  B.  acidophilus,  30 
Mammala,  273,  279 
Marasmus.  207 
Marfan.  178 
McClure,  249 

Mead's  dextrimaltose,  142,  276, 
279 
constipating,   153 
Measurements,  314 
Measures,    domestic,    carbohy- 
drate equivalents,  150 
Meat,  caloric  value,  156 

permitted  at  three  years,  167 
recipes,  294 
Meconium,  25 
Medicine    dropper    in    feeding 

premature  infants,  91 
Mehlnahrschaden,  240 
Meigs.  107 
Mellin's  food,  142,  276 

laxative,  153 
Menstruation    influencing   pro- 
duction  of   milk,  42 
Merriet,  227 

Merrill-Soule   powdered   modi- 
fied milk,  273,  279 
Metabolic  bankruptc}^,  177 
intoxication,  227 
calcium,  145 
Metabolism,  definition  of,  7 
difficulties  in  study,  7 
intermediary,  7 


Metabolism,    mineral    in    arti- 
ficially   fed    and    breast- 
fed infant,  144 
nitrogen  influenced  by  carbo- 
hydrates and  fats,  11 
of  proteins,  9 
sodium  and  potassium,  145 
Meyer,  L.  F.,  112,  146,  177,  250 
Micrococcus  ovalis,  25,  26,  27 
Milchnahrschaden,    186,   187 
Milk,    albumin,    caloric    value, 
150 
bacteria,  113 
caloric  value,  156 
chymogen,  caloric  value,  150 

recipe,  282 
coagulation  differences,  20 
composition,  8 
digestion,  20 

excessive,     colic     and     flatu- 
lence, 169 
fat,  112 

for  nursing  mother,  40 
lactose,  112 
overfeeding,  186 
sahs,  112 
station,  297 

breast,  human,  mother's,  cal- 
oric value,  149 
conditions  influencing  pro- 
duction, 42 
examination,  36 
expression,  61 
ferments,   36 
idiosyncrasy,  86 
immunizing  bodies,  36 
influencing  intestinal  flora, 

29 
quantity  obtained  by  nurs- 
ing infant,  72 
stomach  digestion,  21 
value,  36 
cow's,   adaptation   for  infant 
feeding,  124 
boiling,    changes,    109,    119, 
121 
constipation,  119 
methods,   12^ 


INDEX. 


333 


Milk,  sterilization  and  pasteur- 
ization, 119 
caloric  value,  149 
,     certified,  115 

vs.  boiling,  122 
condensed,  273,  277 
and  soy  bean,  288 
cooling,  114 

curds,    methods    of    break- 
ing, 154 
evaporated,  273,  277 
frozen,  117 
home  care,  115 
idiosyncrasy,  173,  187 
infected,  dyspepsia,  196 
inspected,  116 
intestinal  flora,  29 
larosan,  294 
market,  117 

maternal  compared,  110 
milking,  114 

minimal  requirements,  151 
mixed  vs.  milk  of  one  cow, 

117 
pasteurization  (double  boil- 
er), 281 
pasteurization    vs.    boiling, 

122 
powdered,  273,  279 
quantities  to  be  fed,  151 
raw,    excessive,    dyspepsia, 

196 
skim,  caloric  value,   149 
spoiled,  intoxication.  223 
nutritional     disturbances, 
180 
sterilization    (double    boil- 
er), 281 
stomach  digestion,  21 
Milking,  114 
Mixed  feeding,  67 
Monosaccharides,   13 
Mother,  neurotic,  36 
nursing,  age,  36 
air,  41 

alcoholic  drinks,  75 
appetite,  74 
baths,  75 
breasts,  care,  42 


Mother,   nursing,   breast   infec- 
tions, 85 
constipation,  40 
diet,  39 
drugs,  43 
exercise,  41 
general  infectious  diseases. 

85 
menstruation,  42 
mental  condition,  43 
Wassermann   reaction,  ^7 
Mouth,  bacteria,  26 
milk  digestion,  20 
physioloev,  4 
M tiller,  293 
Multiparity,  wet  nurse,  48 

Nahrzucker,  Sohxlet,  276,  279 
Nasal  spoon  feeding  of  prema- 
ture infants,  91 
Nationality,  wet-nurse,  47 
Naunyns,  15 

Neoplasm,  malignant,  contrain- 
dication to  nursing,  38 
Nephritis,    contraindication    to 
nursing,  ZS 

enteral  infections,  261 
Nestle's  food,  274 
Nipples,  295 
Nitrogen  equilibrium,   135 

retention,  137 
Nuclein  in  milk,  8 
Nursing,  35,  43 

ability,  35 

axioms,  39 

both  breasts,  44 

contraindications,  2)7 

early,  35 

length,  Z6 

length  of  each  period,  45 

maternal,  39 

night,  45 

number  in  a  day,  45 

one  breast,  44 

proper  method  of  holding  the 
baby,  59 

regularity,  43 

signs  of  successful,  64 

time,  82 


334 


INDEX. 


Nurse,  wet-,  see  Wet-nursing. 

Nutritional    disturbances,    arti- 
ficially fed  infants,  168 
breast-fed  infants,  71 
classification,  182 
congenital  debility,  184 
diagnosis,     alimentary     from 
those   due   to   infections, 
248 
differential,  185 
etiology  in  general,  177 
general  consideration,  175 
general  symptomatology,  180 
insufficient  food,  238 
mixed  forms,  237 
overfeeding,  179,  183 
secondary,  183 
tolerance  lessened,  179 
underfeeding,  179,  183 

Nutrol,  276 

Oatmeal  jelly,  280 

water,  280 
Opalisin  in  milk,  8 
Orange,  gelatin,  290 
juice,  155 
recipe,  290 
Otitis,     parenteral     infections, 

249 
Overfeeding,  artificiallv  fed  in- 
fant, 179 
breast-fed  infant,  1^ 
dyspepsia,  196 
Oxaluric  bodies  in  urine.  10 

Pack,  cold,  30^ 

hot,  303 
Pain,  abdominal,  enteral  infec- 
tion, 258,  260 
Pallor,  disturbed  metabolic  bal- 
ance, 186 
Pancreas,  ferments  of,  5 
Pap,  291 

Paradoxical  reaction,  181 
decomposition,  210 
disturbed   metabolic   balance, 
189 
Paranuclein,  9 


Paratyphoid,    enteritis,    pathol- 
ogy, 257 
Pavlow,  4 
Peas,  green,  290 
Pedatrophy,  207 
Pegnin,  276 
Pepper,  107 
Pepsin,  5,  276 
action  on  paranucleins,  9 
digestion  of  casein  by,  9 
Peptogenic    powder     (Fair- 
child's),  276 
Peptones,  9 
Peristalsis,  visible,  overfeeding 

on  the  breast,  79 
Pfaundler,  2,  178 
Phagocytosis  increased  by  cal- 
cium salts,  18 
Pharyngitis,  breast-fed  infants, 

85 
Phosphorus,    excretion    de- 
creased by  fats,  17 
in  milk,  17 
Plasmon,  276 

Pneumonia,    breast-fed    infant, 
85 
enteral  infections,  261 
nursing  mother,  85 
parenteral  infections,  249 
Polysaccharides,  13 
Potassium  and  sodium  metab- 
olism, 145 
in  milk,  16 

salts    favoring    fermentation, 
30 
Potato,  caloric  value,  157 

recipe,  289 
Pregnancy    as    indication     for 

weaning,  68* 
Premature  infants,   amount  of 
each  feeding,  101 
artificial  feeding,  102 
daily  gains,  102 
decomposition,  208 
methods  of  feeding,  89 
number  of  feedings  daily,  100 
Prematurity,    congenital    debil- 
ity, 84 
Prosecretion,  5 


INDEX. 


33: 


Proteins,  chemistry,  8,  135 

decomposition,    31,    33,    173, 
177 

disturbed   metabolic   balance, 
186,  188 

equilibrium,  135 

excessive,    disturbed    metab- 
olic balance,  190 

feces,  22 

foreign  to  human  body,  177 

functions,  10,  134 

metabolism,  9 

putrefaction  favored,  30 

quantities    in   artificial    feed- 
ing, 136,  161 

requirements,  136 

stomach  digestion,  20 

stools,  22 

sugars  and  starches,  137 
Prune  jelly,  290 

juice,  290 
Psychoses,   contraindication    to 

nursing,  38 
Ptyalin,  4 

polysaccharides,  13 
Pudding,  cornstarch,  291 

custard,  292 
Puerperal     fever,     nursing 

mother,  85 
Pulse,  average  rate,  316 

slow^,  decomposition,  213 

small,  irregular,  intoxication, 
231 
Purpura,   decomposition,  213 
Putrefaction,  22,  29,  30 

calcium  salts,  30 
Pyemia,  enteral  infections,  261 
Pyelitis^  breast-fed  infant,  86 

overfeeding  on  the  breast,  80 

parenteral  mfections,  249 
Pylorospasm,  184 
Pylorus,     overfeeding    on    the 
breast,  80 

stenosis,  85 
Pyodermatoses,    enteral    infec- 
tions, 261 

Quest's  figure,  214 


Rachitis,   boiled   milk,    120 

disturbed   metabolic   balance. 
192 

salts  absorption  deficient,  18 
Record  sheet,  318 
Rectal  feeding,  306 

medication,  307 
Regurgitation,    overfeeding    on 

the  breast,  77 
Rennet  powder,  276 
Rennin,  5 

Reparation  stage,  216 
Respiration,    average   rate,   316 

Cheyne-Stokes,  decomposi- 
tion, 213 

rapid,   decomposition,  213 

toxic,  231 
Restlessness,    disturbed   metab- 
olic balance,  186 

dyspepsia,  198 
Rice,  caloric  value,  157 

water,  280 
Ringer's  solution,   intoxication, 

232 
Robinson     patent     barlevflour, 

274 
Rosenstern,  216,  226 
Rotch,  108,  126 
Rubner,  108,  136,  137,  147 
Ruhrah,  288 

Saccharose,  caloric  value,  150 

lactose  compared,  141 
Salge,  113 

Saline  solutions,  308 
Saliva,  secretion,  20 
Salivary  glands,  1 
Salts,  15 

chemistry,  15 

excretion  by  large  intestine,  6 

functions,  18,  143 

human  and  cow's  milk,  143 

metabolism,  17 

nitrogen  retention,   137 

solutions,  308 

withdrawal    influencing 
weight,  18 
Saner,  249 
Schloss,  293 


336 


INDEX. 


Sclerma  in  intoxication,  231 
Scurvy,  boiled  milk,  120 
"Second  summer,"  69 
Sensorium,  decomposition,  213 

intoxication,  230 
Sepsis,  nursing  mother,  85 
Shaw,  310 
Skatol,  30 
Sleep  disturbed,  186 

length,  315 
Smillie,  254 
Smith,  263 
Soaps,  intestines,  17 

stools,  12 
Sodium  and  potassium  metab- 
olism, 145 

citrate  to  break  curds,  154 

in  milk,  16 

salts  and  water  retention,  18 
favoring  fermentation,  30 
Sohxlet-Nahrzucker,  276 
Solutions,  saline,  308 
Soup,     chicken,    caloric    value, 
157 

cream,  286 

dried  fruit.  288 

farina,  287 

Keller's    malt,    caloric   value, 
150 
recipe,  286 

permitted  at  three  3'ears,  167 

vegetable,  caloric  value,  157 
recipe,  287 
Soy  beans  and  condensed  milk, 

288 
Spasmophilia,  184 
Spinach,  289 
'•Spitting,"  78,  168 
Stadium  dvspepticum,  196 
Starches,  addition,  153 

constipating  tendency.  24 

nitrogen  retention,  137 
Startoline,  283 
Steapsin,  5 
Steinitz,  240 
Stomach,  absorption,  20  - 

acidity,  4 

anatomj^,  1 

bacteria,  26 


Stomach,  capacity,  2 

ferments,   5 

gas,  170 

milk  digestion,  20 

physiolog}^,  4 

washing,  304 
Stools,  see  also  Feces. 

abnormal,  171 

blood,  173 

composition,  21 

curds,  171 

decomposition,  213 

diagnostic  value,  24 

disturbed    metabolic    balance, 
189,  190 

dyspepsia,  200 

enteral  infections,  259 

examination,  8 

fat-soap,  139,171,  173 
pathogenesis,  187 

fats  in,  12 

flour  injur}^,  242 

hunger,  24,  IZ,  171,  243 

intoxication,  230 

Keller's  malt  soup,  171 

loose,  green,  172 

nitrogenous  bodies  in,  10 

normal,  23 

nursing  infant,  65 

starvation,  see  Hunger. 

sj^mbols,  317 

underfeeding  on  breast,  IZ 
Strabismus,  intoxication,  230 
Streptococcus,  31,  254 

enteritis,  255 
Stupor,  intoxication,  230 
Subcutaneous    saline    solutions, 

308 
Sublingual    tumors,    congenital 

debility,  85 
Sugar,  cane,  see  Saccharose. 

excessive,  dyspepsia,  196 

intoxication,  226 

laxative  tendency,  24 

malt  causing  brown  color  of 
stool,  24 

milk,  see  Lactose. 

nitrogen  retention,  137 


INDEX. 


337 


Sugar,      quantities      in      infant 
feeding,  142 

vomiting,   169 
Summer  diarrhea,  223 

etiology,  249 
Supplemental  feeding,  67 
Syphilis,      contraindication      to 
nursing,  37 

decomposition,  207 

hereditary  weakness,  84 

Tea,  recipe.  279 
Teeth,  deciduous,  315 

permanent,  316 
Teething,  1 
Temperature,  carbohydrates,  15 

extremes,  dyspepsia,   156 

salts,  18 

subnormal,  decomposition, 
212 
Tenesmus,     enteral     infection, 

258,  260 
Tetany,  flour  injury,  241 
Therapeutic  dietetic  test,  250 
Thrush,  dj^spepsia,  199 
Toast,  caloric  value,  157 
Tobler,  20 
Tonsillitis,  breast-fed  infant,  85 

parenteral   infections,  249 
Toxemias,  acute,  31 
Traveling,  care  of  food,  297 
Trypsin,  5 

Tuberculin  test,  cow,  113 
Tuberculosis,     contraindication 
to  nursing,  37 

cow,  113 

decomposition,  207 

hereditary  weakness,  84 
Turgor  of  the  tissues,  131 
Twitchings,    intoxication,   230 
Typhoid,     epteritis,    pathology, 
257 

nursing  mother,  85 

Underfeeding,     breast-fed     in- 
fant, 71 
nutritional  disturbances,  179 
Underdevelopment  due  to 
boiled  milk,  120 


Unger,  310 
Urea,  10 

Uric  acid  in  urine,  10 
Urine,  24 
ammonia     increased,     in     in- 
toxication, 227 
daily  quantity,  316 
decomposition,  213 
disturbed    metabolic    balance, 

190 
end  products  of  protein  me- 
tabolism, 10 
ethereal   sulphates   increased, 

31 
examination,  8 
fat,  12 

intoxication,  231 
sugar,  14 
symbols,  317 

Van  Slyke,  154,  155 
Vegetable,   caloric  value,   157 

permitted  at  three  years,  167 
Vomiting,  artificial  feeding,  168 

decomposition,  212 

dyspepsia,  200 

enteral  infections,  260 

habitual,   184 

intoxication,  230 

overfeeding  on  the  breast,  78 

Wassermann  reaction,,  mother's 
blood,  37 

wet-nurse,  49 

wet-nurse's  infant,  50 
Water,  18,  145 

absorption     by     large     intes- 
tine, 6 

artificial   feeding,   152 

content  of  the  organism,  19 

excretion,  19 

function,  146 

metabolism,  18 

nursing  infant,  45 

retention.  146 

weight,  146 
Weakness,  hereditar}-,  84 
\\>aning,  67 

care  of  breasts,  69 


22 


338 


INDEX. 


Weaning,  indications,  68 
method,  69 

overfeeding  on  the  breast,  82 
Weigert,  240 

Weight,   artificially   fed  infant, 
131 
average,  314 
carbohydrates,  14 
disturbance,  186 
disturbed   metabolic   balance, 

189 
failure  to  gain  in  breast-fed, 

1Z 
fluctuations,  flour  injur\',  241 
gain,  flour  injury,  241 
infections,  250 
successful  nursing,  65 
loss,  decomposition,  210 
disturbed     metabolic     bal- 
ance, 188 
dyspepsia,   199 
enteral   infections,   258 
infections,  250 
intoxication,  230 
salt  withdrawal,  18 
stationary,    168 

disturbed     metabolic     bal- 
ance, 186 
artificial  feeding,  168 
overfeeding  on  breast,  79 
water,  146 


Wet-nurse,  47 

age,  48 

baby,  50,  52 

clothes,  54 

cost  of  milk,  52 

diet,  55 

examination,  48 

exercise,  56 

hygiene,  54 

length  of  lactation,  52 

menstruation,  57 

mental  state,  57 

multiparity,  48 

nationalit}',  47 

number  needed,  52 

period  of  lactation,  57 

place  in  household,  51 

quantity'  of  milk,  51 

quarters,  51 

requirements,  48 

selection,  47 

urine,  50 

Wassermann   reaction,  49 

work,  56 
Wheat  jelly,  280 
Whey,  dyspepsia.  198 

recipe,  282 
Widerhofer,  175 

Zuckernaehrschaden,  196 


1 

DUE  DATE 

1 

MAR 

1     "^^     I^Ol        i 

^PR  3 

F»  t  ' 

94 

# 

201-6503 

Printed 
in  USA 

V\'<fe 


6  iyi3 


COLUMBIA 


UNWERSlTVyBRA^^^^^^ 


0037552031 


W!' 


iiii 


